Membership Form Silver Bay Ymca
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1
2For office use only:
Received
Open Pathways %
87 Silver Bay Road ▪ Silver Bay, NY
12874 518.543.8833
Host
Badges
Raiser’s Edge
Membership Form 2014
Silver Bay YMCA is a membership organization. Basic Membership is required to make a reservation and enjoy
the campus. Program Membership is required to enjoy all the programs and activities at Silver Bay. On-
Campus guests have all the privileges of a program member for the duration of their stay.
Membership Information
Title
First Name
Nickname
M.I.
Last Name
Maiden Name
Suffix
Birth
Gender
(optional)
(if applicable)
Date
Permanent Address
Summer Address(if applicable)
Street/PO Box:
Street/PO Box:
City:
City:
State:
Zip Code:
State:
Zip Code:
Home Phone:
Summer Phone:
Work Phone:
Summer Dates from:
to
Cell Phone:
Do you prefer to receive mail at this address?
Email Address:
Yes
No
Family Membership includes married couples or up to two adults, all dependent children through the age of
18 and full-time college students through the age of 24, residing in the same household. (Proof of residency or
college proof may be required.)
Step 1: List below the individuals to be included in your membership and/or program package.
Title
First Name
Nickname
M.I.
Last Name
Suffix
Maiden Name
Relationship
Birth
Gender
(optional)*
(if applicable)
Date
*Nickname will be used on badges.
Please review the statements below:
Part A: I agree to hold Silver Bay YMCA harmless for injuries and accidents that may occur during my time at
Silver Bay. If I am a parent or guardian, I accept full responsibility for supervising my children at all times,
unless they are in a registered Silver Bay program.
Part B: I understand members and program participants may be photographed for publicity purposes, if you or
any other person on your membership wishes not to be photographed, a Do Not Photograph request must be
submitted, in writing, prior to visiting the campus or participation in any Silver Bay program or activity.
I have read and understand both Part A & Part B.
Signature______________________________________________________Date_____________
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