Membership Application Form
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4Membership
Application
Type of Membership
Additional Services
__ Caldwell
___ Adult (19-24)
___ Short-term adult
___ Individual towel plan
__ Downtown
___ Adult (25-64)
___ Short-term youth
___ Family towel plan
__ West Y City
___ Short-term family
___ Locker rental (#_________)
___ Adult (65+)
__ Homecourt
___ Youth (10-18)
___ West aquatic member
___ Child Watch (1 child)
__ Staff
___ Program member
___ Child Watch (2+ children)
___ Family
___ Silver Sneaker
___ Other: ________________
___ 2 youth
Primary Adult (required for youth under 18)
First name
Middle name
Last name
Formal first name
Gender
Date of birth
Street address
City
State
Zip
Home phone
Cell phone
Email Address
Additional Family Members
Name (first, middle, last)
Age
Birth date
Gender
Relationship to member
School
Name (first, middle, last)
Age
Birth date
Gender
Relationship to member
School
Name (first, middle, last)
Age
Birth date
Gender
Relationship to member
School
Name (first, middle, last)
Age
Birth date
Gender
Relationship to member
School
Name (first, middle, last)
Age
Birth date
Gender
Relationship to member
School
Emergency Contacts
Name
Phone
Relationship to member
Name
Phone
Relationship to member
STRONG KIDS CAMPAIGN
The Strong Kids Campaign raises funds to assure that
no child is turned away from a YMCA program or service
because of financial challenges their families may face.
___ I would like to make a difference in the life of a child
by giving to the Strong Kids Campaign.
If interested in volunteering please inquire at the
Welcome Center.
(Over)
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