Ymca Of The Inland Northwest Membership Application
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1
2YMCA OF THE INLAND NORTHWEST
MEMBERSHIP APPLICATION
Central YMCA
Valley YMCA
North YMCA
Youth
Young Adult
Adult
2 Adult Family
1 Adult Family
Senior Adult
Senior Adult Family
ANNUAL CAMPAIGN DONATION
Your generous contribution to the Annual Campaign supports children and families in our community. I want to help those in need participate
in YMCA activities through my following gift:
________________________________________________
$25
$15
$10
$5
Other ____________________________________
Signature
Date
One Time Payment
Monthly Draft
(occurs on the 21st of each month for the remainder of the year)
PRIMARY MEMBER
ID NUMBER: ___________________________________________
First Name
Middle
Last Name
Date of Birth
Gender
Preferred email
Please send me emails about
/
/
M
F
YMCA programs and events
Street
Apt/Unit #
City
State
Zip
Home Phone
Cell Phone
(
)
(
)
Employer Name
Position/Occupation
Work Phone
(
)
2nd ADULT MEMBER
or Parent/Guardian for applicants under 18 years
First Name
Middle
Last Name
Date of Birth
Gender
Preferred email
Please send me emails about
YMCA programs and events
/
/
M
F
Street
Apt/Unit #
City
State
Zip
Home Phone
Cell Phone
(
)
(
)
Employer Name
Position/Occupation
Work Phone
(
)
DEPENDENTS
First Name
MI
Last Name
Date of Birth
Gender
Relationship to Primary Adult Member
/
/
M
F
/
/
M
F
/
/
M
F
/
/
M
F
/
/
M
F
EMERGENCY CONTACT
First Name
Phone
(Other than in your household)
(
)
Required for all memberships
Please complete reverse side
2015-02
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