Eligibility Form
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1_____ NEW ____RENEWAL
YMCA Member ID# _______________
YMCA/DoD ELIGIBILITY FORM- (TITLE 10 ONLY)
TITLE 32 PERSONNEL ARE NOT ELIGIBLE.**
Revised 10/8/09
SPONSOR NAME/PAYGRADE____________________________________ DATE: ____________
PHONE # WHERE YOU CAN BE CONTACTED ________________________________________
SERVICE BRANCH: ____ ARMY ____ MARINE CORPS ____ NAVY ____ AIR FORCE
STATUS: ____ DEPLOYED RESERVE ____ DEPLOYED NATIONAL GUARD ____ ACTIVE DUTY
**Those eligible are Families of Deployed National Guard and Reserves, Relocated Spouse of
Deployed Active Duty Personnel, and Active Duty Assigned to Independent Duty Locations. (I D P
must also complete Independent Duty Eligibility Request Form and get POC approval.
Contact Military OneSource at 1-800-342-9647 with questions.
DUTY STATION: _____________________________________________
SPOUSE’S NAME: ____________________________________________
(Single deployed service members are not eligible. Spouse or Single parent families are eligible.)
PHONE # WHERE YOU CAN BE CONTACTED ________________________________________
CHILDREN’S NAMES:
___________________________________ BIRTHDATE: _______________ AGE: ______
___________________________________ BIRTHDATE: _______________ AGE: ______
___________________________________ BIRTHDATE: _______________ AGE: ______
___________________________________ BIRTHDATE: _______________ AGE: ______
___________________________________ BIRTHDATE: _______________ AGE: ______
HOME EMAIL ADDRESS (Optional): ________________________________________________
DEPLOYMENT DATE RANGE: (Must be 6 months or more)__________________________________________
MUST HAVE VISITED 8 CALENDAR DAYS PER MONTH TO BE ELIGIBLE FOR RENEWAL
__________________________________________________
Signature of Sponsor or Spouse for attendance requirements
I certify that I am/my spouse is TITLE 10 and therefore eligible for YMCA membership in one of the
authorized categories.
__________________________________________________
Signature of Sponsor or Spouse for Title 10 eligibility
---------------------------------------------------------------------------------------------
FOR YMCA USE ONLY
Stephens Family YMCA, 2501 Fields South Drive, Champaign, IL 61822
VIEW REQUIRED DOCUMENTS (
)
____ DEPLOYMENT ORDERS ____ MILITARY ID
must initial one
ELIGIBILITY: (TITLE 10 ONLY) (YMCA Staff Must Initial)
____ JOINT BASE – USED FOR RENEWAL ONLY AS OF *OCT 2009*
____ DEPLOYED NATIONAL GUARD / RESERVE FAMILY MEMBER
____ ACTIVE DUTY RELOCATING SPOUSE
____ INDEPENDENT DUTY PERSONNEL- Requires completed Active Duty Military ID and
Request for
Title 10 Independent Duty Personnel (IDP) Fitness Memberships/Respite Care Authorization with signature of
Commanding Officer and POC signature. * Commander to Contact Military One Source for Email Address
/Contact Info for Military Service POC Approval.
DATE MEMBERSHIP ACTIVATED: _____/_____/_____
MONTHLY RATE CHARGE $______ x 6 = $__________
YMCA staff may contact Armed Services YMCA at 703.313.9600 for additional information.
DoD reserves the right to review membership records for audit purposes.
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