Program Membership And Participant Information - Ymca Of Metropolitan Chicago

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PROGRAM MEMBERSHIP AND PARTICIPANT INFORMATION

APPLICATION FOR MEMBERSHIP

FULL

LIMITED

CORPORATE

(Program Only)

YMCA OF METROPOLITAN CHICAGO

1030 W. Van Buren Street, Chicago, IL 60607 | 312.932.1200 |

MS.

FIRST NAME

M.I.

LAST NAME

NAME

MRS.

MR.

STREET

HAVE YOU EVER HAD A MEMBERSHIP OR REGISTERED FOR A

PROGRAM AT ANY YMCA OF METROPOLITAN CHICAGO BEFORE?

YES

CITY

STATE

ZIP CODE

I NEED A MODIFICATION BECAUSE OF DISABILITY TO ENJOY

THIS PROGRAM.

YES

HOW DID YOU HEAR ABOUT THE YMCA?

HOME PHONE/

CELL PHONE

Radio

Print Ad Mail

Online

Website Facebook

School/Work

EMAIL ADDRESS

WHAT ARE YOUR INTERESTS?

Fitness Aquatics Sports Child Care Camp

EMPLOYER/SCHOOL

WERE YOU REFERRED BY A YMCA OF METRO CHICAGO MEMBER?

ID#:

BIRTHDATE

SEX

RACE (CIRCLE ONE-OPTIONAL)

PERSONAL

WHITE

BLACK

HISPANIC

ASIAN/PACIFIC ISLANDER

AM. INDIAN/ALASKAN

INFORMATION

I T

P I

EMERGENCY CONTACT #1

CHECK

TO OPT OUT OF

TEXT MESSAGE

EMERGENCY CONTACT #2

NOTIFICATIONS

FAMILY MEMBERS

L (

F I

) T

R I

EMPLOYER / SCHOOL / CORPORATE AFFILIATION

SPOUSE/PARTNER

EMPLOYER

Name:

SCHOOL

CORPORATE AFFILIATION

CHILDREN

EMPLOYER

Name:

SCHOOL

CORPORATE AFFILIATION

EMPLOYER

Name:

SCHOOL

CORPORATE AFFILIATION

EMPLOYER

Name:

SCHOOL

CORPORATE AFFILIATION

EMPLOYER

Name:

SCHOOL

CORPORATE AFFILIATION

EMPLOYER

Name:

SCHOOL

CORPORATE AFFILIATION

OFFICE USE

METHOD OF PAYMENT

INITIAL PAYMENT

BRANCH LOCATION

MEMBERSHIP ID #

CREDIT CARD DRAFT ______

VISA

CHECK

BANK DRAFT

______

MASTERCARD

CASH

YOUNG

YOUTH

INDIVIDUAL

ADULT

FAMILY

ADULT

HOUSEHOLD

ANNUAL

______

AMEX

DISCOVER

ENROLLED BY

______

QUARTERLY

______

MONTHLY

Additional information:

ENROLLED BY:

FITNESS CONSULTATION:

YES

VERIFIED BY:

I HAVE READ, UNDERSTAND, AND AGREE TO ALL THE INFORMATION ON THE BACK OF THIS FORM. I FURTHER EXPRESSLY AGREE THAT THE ASSUMPTION OF RISK, RELEASE,

Initial

Here

WAIVER AND INDEMNITY AGREEMENT IS INTENDED TO BE AS BROAD AND INCLUSIVE AS IS PERMITTED BY THE LAW OF THE STATE OF ILLINOIS AND IF ANY PORTION THEREOF IS HELD

INVALID, IT IS AGREED THAT THE BALANCE SHALL, NOTWHITHSTANDING, CONTINUE IN FULL LEGAL FORCE AND EFFECT. I ALSO UNDERSTAND AND AGREE THAT IF THE MEMBERSHIP IS

INTERUPTED FOR ANY REASON THESE AGREEMENTS WILL REMAIN IN EFFECT DURING THE PERIOD OF INTERRUPTION AS WELL AS AFTER THE MEMBERSHIP IS REINSTATED.

SIGNATURE ____________________________________________________________________________________________________________

DATE___________________________

(APPLICANT)

SIGNATURE ____________________________________________________________________________________________________________

DATE___________________________

(SPOUSE/PARTNER)

SIGNATURE ____________________________________________________________________________________________________________

DATE___________________________

(18+ YEAR-OLD CHILD IN FAMILY MEMBERSHIP)

SIGNATURE ____________________________________________________________________________________________________________

DATE___________________________