Application For Ymca Membership Form printable pdf download

Application for YMCA Membership

First Name___________________ MI. ____ Last ___________________ ο M

ο F

Birth Date ___ / ___ / ___

Spouse First Name___________________ MI. ____ Last ___________________ ο M ο F

Birth Date ___ / ___ / __

Address _________________________________________________________________________

City __________________________________ State _____________________ Zip Code __________ - _________

Home Phone ____________________________________

E-mail Address

_________________________________

Your Occupation _______________________________________ Employer _________________________________

Spouse Occupation _____________________________________ Employer _________________________________

Emergency Contact #1 ________________________ Relationship _______________ Phone ___________________

Emergency Contact #2 ________________________ Relationship _______________ Phone ___________________

Family Membership Information (List Last Name if Different)

Dependent/Children’s Names

M/F

Birth Date

Relationship

School

Grade

To help us serve you better, please fill out the following information. This information is kept confidential.

How did you hear about the Y? ο Newspaper ο TV ο Radio ο YMCA Brochure ο Member ο Billboard ο

Internet ο Other

What are looking to do most at the Y?_______________________________________________________________

Income Level of Household:

ο Under $30,000 ο $30,001 to $50,000

ο $50,001 to $70,000

ο $70,001 +

Ethnicity:

ο Asian ο African-American ο Hispanic ο Latino ο Caucasian ο Other: ___________

The YMCA is a volunteer-driven organization. We utilize volunteers in our programs such as YMCA Youth Swim

Lessons, special events like YMCA Family Day, and facility projects like Annual Spring Clean-up. We can certainly use

your help.

Would you like a staff member contact you regarding volunteer opportunities at this time?

Yes

If yes, what special skills do you have? __________________________________________________________

(e.g. carpenter, coaching, plumber)

What would area are you interested volunteering in? ____________________________________________________

(e.g. youth sports coach, facility, special events)

In consideration of gaining membership or being allowed to participate in the activities and programs of the YMCA and

to use its facilities, equipment, and machinery in addition to the payment of any fee or charge, I do hereby waive,

release, and forever discharge the YMCA and its officers, agents, employees, representatives, executors, and all

others from any and all responsibilities or liability for injuries or damages resulting from my participation in any

activities or my use of equipment or machinery in the above mentioned facilities or arising out of my participation in

any activities at said facility. I do also hereby release all of those mentioned and any others acting upon their behalf

from any responsibility or liability for any injury or damage to myself, including those caused by the negligent act or

omission of any those mentioned or others, acting on their behalf or in any way arising out of or connected with my

participation in any activities of the YMCA or the use of any equipment at the YMCA. I agree to adhere to all policies

set by the YMCA. All memberships are non-refundable or transferable.

Signature _________________________________________________ Date ______________________________

ο Full Pay ο E.F.T. ο Other:____________________

Join Date: _____________________

ο Family ο Adult Individual ο Youth

ο Senior ο Other: __________________________________

Type of Membership:

ο Promotional membership ο Basic ο Complete

Entered ___

Please consider making a donation to our “Reach Out For Youth” campaign. You can make a difference.

$5_____$10_____$50_____$100 +_____

Application For Ymca Membership Form

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