American University'S Recreational Sports And Fitness Registration Form
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Member Data (Please Print)
Today’s Date ______________
Name ____________________
__________________________
____
First
Last
M.I.
Date Of Birth ____________________
Gender: (circle one) M
F
AU ID # ______________
JFC #______________
Expected Date of Graduation
(Student/STAFF/FAC) (Non Students Only)
(AU students only) ___________
Month/Year
Current Address
Street ___________________________________________________
Apt.#__________________
Email______________________________________
City/State/Zip_____________________________________________
Home Phone # (____)-_________-_________
Work Phone # (_____)-________-_________
Emergency Information
Emergency Contact Person
Name____________________________________
Phone # (____)-________-________
Physician’s Name___________________________
Phone # (____)-_______-_________
Member Status (office use only)
AU Student
Alumni
□ Undergraduate
□ Individual
□ Graduate/PhD/JD
□ Family (primary member) ____________________
□ Washington Semester (end date: ______)
□ Family (primary member) ______________
Faculty
Community
□ Full-time (12-month ___ / 9-month ___)
□ Individual
□ Part-time
□ Family (primary member) ____________________
□ Family (primary member) _______________
Staff
Other
□ Full-time
□ Wesley Student
□ Part-time
□ Wesley Faculty/Staff
□ FAC/STAFF student
□ Osher Lifelong Learning Institute
□ Family (primary member) ______________
□ Complimentary___________________
□ Corporate (vendor) ___________________
□ Other ____________________
Office Use Only
Expiration Date________________________
Month /Day/ Year
Payment Type (check one) ____Cash
____Check ____ Payroll Deduction ____Credit Card
Check # __________ Amount ____________ Staff Initials_______
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Parent category: Life