Fair Acres Family Membership Application Form
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1
2FAIR ACRES FAMILY YMCA MEMBERSHIP APPLICATION
MEMBERSHIP TYPE - CIRCLE ONE
(0-18)
(19-23)
(24-55)
(55 and up)
(Both 55 and up)
Youth
Young Adult
Adult
Family
Senior
Senior Couple
Name: ___________________________________________ Birth date: __________ Gender: _____
Additional Family Members to be included on membership: (Family is husband, wife & all dependents 23 & under)
_______________________________ Relation _________ Birth Date __________ Gender _____
_______________________________ Relation _________ Birth Date __________ Gender _____
_______________________________ Relation _________ Birth Date __________ Gender _____
_______________________________ Relation _________ Birth Date __________ Gender _____
Address: ____________________________________________
Home Phone: _________________
City: __________________________
Zip Code:__________
Email: _______________________
Cell Phone:_____________________________________Spouse’s Cell Phone:_______________________
Employer: ___________________________________________ Work Phone: _______________________
Spouse’s Employer: ___________________________________ Work Phone: _______________________
Emergency Contact: (Please include name, address, phone)
How did you hear about the YMCA? _____________________________________________________
Are you interested in Volunteering at the YMCA? _______________________________________________
Optional Information for YMCA Records Only:
Ethnicity:
Asian
African American
Hispanic
Native American
White
Other
Income Level:
Under $13,999
$14,000 - $24,999
$25,000 - $39,999
$40,000 - $54,999
$55,000 - $74,999
Over $75,000
By signing this form, I (we) agree to follow the rules and policies of the YMCA. I understand that the YMCA does not carry accident
insurance and agree to use my personal insurance as needed. I agree not to hold the YMCA or its staff, Board of Directors, volunteers or
sponsors responsible for injuries or accidents. I authorize the YMCA to obtain medical care in the event of an injury or accident if a family
member is unavailable to give permission. I give my permission to the Fair Acres Family YMCA to use indefinitely, without limitation or
obligation, photographs, film footage or tape recordings, which may include image or voice for purpose of promoting or interpreting YMCA
programs. I understand that YMCA memberships are non-transferable, and in order to cancel my bank draft/credit card charge I must give
written notice to the YMCA 30 days prior to the day of the month I wish to cancel.
______________________________________________________
___________________
Signature
Date
FOR OFFICE USE ONLY
Date:
Check one:
____New Member
____Renewal
____Rejoin
____Temp
Billing Method (Check one): ____Bank Draft ____Credit Card Draft
____Pay in Advance
Billing Cycle:
Membership Type :
Prorated Amt. Paid
Joiner’s Fee:
Received By
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