Greater Pittston YMCA Membership Application

 

Type of Membership: ______________________________

 

 Please Complete All Information

 

1st Adult                                               

 

Today’s Date: ___________

 

First Name_______________________MI .____ Last Name_______________________

 

Gender: __M __F                  Date of Birth:____________________________________

 

Marital Status:  Single  Married  Divorced  Separated

 

Home/Mailing Address:___________________________________________________

 

City:_____________________State:_____ Zip__________Home Phone:_____________

 

Employer:_________________________Work Phone:__________________________

 

Home Email:_______________________Work Email: __________________________

 

Emergency Contact_______________________Phone: __________________________

 

 

2nd Adult                               

 

First Name_______________________MI .____ Last Name_______________________

 

Gender: __M __F                  Date of Birth:____________________________________

 

Marital Status:  Single  Married  Divorced  Separated

 

Home/Mailing Address:___________________________________________________

 

City:_____________________State:_____ Zip__________Home Phone:_____________

 

Employer:_________________________Work Phone:__________________________

 

Home Email:_______________________Work Email: __________________________

 

Emergency Contact_______________________Phone: __________________________

 

Dependents

First Name      MI       Last Name      Date of Birth     Gender          School

 ________________________________________________________________________

________________________________________________________________________

 

  The Greater Pittston YMCA does not grant insurance or carry medical insurance for members or participants, therefore, all members/participants in our programs are at their own risk. The YMCA attempts to conduct all programs in the safest possible manner. However, accidents sometimes do occur. We urge all members/participants to investigate their own medical insurance to assure they have adequate coverage.

 

I have read and understand the above statement and I and/or my child are adequately covered.

 ______________________________________________     _______________

Signature of Member or Parent/Legal Guardian of Member   Date

 

 Waiver and Membership Agreement

 

I am an adult 18 years of age and wish to participate in the Greater Pittston YMCA membership/ program activities. In consideration of being permitted to utilize the facilities, services and programs of the YMCA for any purpose, including but not limited to observation or use of facilities or equipment, or participation in any off-site program affiliated with the YMCA, the undersigned hereby acknowledges, agrees and represents that he/she has, or immediately upon entering or participating, permission to participate in the Greater Pittston YMCA activities.

 

I understand that even when every reasonable precaution is taken, accidents can sometimes happen. Therefore, in exchangefor allowing me to participate in YMCA activities, I understand and expressly  acknowledge that I, for myself, or anyone entitled to act on my behalf, waive and release the YMCA, sponsors, representatives and successors from all claims and liabilities of any kind arising out of my participation in activities at or sponsored by the YMCA. I further agree to indentify and hold harmless the YMCA from any claims or demands arising out of any such injuries or losses. I understand that this release includes any claims based on negligence, action  or inaction of the Greater Pittston YMCA, its staff, directors, members and guests. I have read and understand and am voluntarily signing this authorization and release.

 

I understand that the Greater Pittston YMCA is n ot responsible for personal property lost, damaged or stolen while members and /or program participants are using YMCA facilities, on YMCA properties or involved in YMCA programs.

I give permission to the Greater Pittston YMCA to use limitation and obligation, photographs, film footage or tape recordings which may include my image or voice for the purpose of promotion or interpreting YMCA programs.

 

Membership Agreement

 

YMCA memberships are a continuous membership plan. I understand that this membership will remain in effect for as long as my dues are paid and I retain the membership card issued to me. I further understand that membership dues are non-refundable and non-transferable. Membership cards are the property of the YMCA and must be surrendered upon demand.

 

It is my complete understanding that if I wish to terminate or change my membership in any way, I must give the YMCA a 30 day written notice. If I cancel my membership prior to the one year anniversary of my membership application my account will be charged a one time fee of $75.

 

All membership rates are subject to change with 30 days written notice. I understand that it is my responsibility to notify the YMCA of any change in address, bank account information (if utilizing bank draft for payment of dues) or credit card information/expiration date (if utilizing credit card.)

 

The Joiners Fee is a one time fee as long as you remain active member of the Greater Pittston YMCA. If you choose to cancel or discontinue your membership  for more than 30 days, a Joiner Fee will be charged when you reapply for membership.

 

I acknowledge the waiver and membership agreement set forth above, and being in agreement with the Mission Statement of the Greater Pittston YMCA, hereby apply for membership.

 

Signature_____________________________________________________Date_____________________

 

 

Signature____________________________________________________Date _____________________

 

 

 

Electronic Funds (EFT) or Credit Card Authoriztion

 

I authorize my bank or Credit Card Institution ot honor preauthorized Electronic Fund Transfers (EFT’s) drawn by the Greater Pittston YMCA on my account for membership/program/contribution payments as indicated below. When the bank (or Credit Card institution) honors the EFT by charging my account, such transfer shall constitute notice of payment due and my receipt for the payment. Should any preauthorized EFT or Credit Card  not be honored by said bank when received by them, then it is understood that this payment is to be made by me in the amount of said payment plus applicable service charge. It is further understood that if such payment is not honored by the bank or Credit Card institution, then the YMCA, at it’s discretion, may resubmit the amount due for payment on a future date.

 

I have read and understand the above statement.

 

Signature_________________________________________________Date_________________________

 

____ I choose to utilize the EFT option for monthly payment from my ______Checking   _____Savings

 

Bank Name: ___________________________________Name on Acct.__________________________

 

Routing No.: _________________________________Account No.: ____________________________

 

Authorized Signature_________________________________________Date_______________________

 

_____I choose to utilize the Credit Card payment option (automatic direct charge to credit card)

Credit Card Type:   ____Visa    _____MasterCard   ______American Express   ______Discover

 

Name on Credit Card: ____________________________________________________________

 

Account No.: ___________________________________________________________________

 

Expiration Date_____________________________________

 

Authorized Signature ___________________________________Date_______________________