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Greater Pittston YMCA Membership Application |
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Membership Type Youth (Ages 0-13) _____ Yearly High School (Ages 14-17) _____ 3 Mo _____6 Mo _____Yearly Young Adult (Ages 18-23) _____ 3 Mo _____ 6 Mo _____ Yearly Adult (Ages 24-61) _____ 1 Mo _____3 Mo _____ 6 Mo _____ Yearly Senior Citizen (Age 62+) _____ Yearly 1 Parent Family _____ 3 Mo _____ 6 Mo _____ Yearly Family* _____ 3 Mo _____ 6 Mo _____ Yearly Kit Locker _____ Monthly ($3 per mo) _____ Yearly ($35) Date:____________ · Family is defined as two (2) adults+ any number of children residing in the same household including full time students up to age 23 |
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Please Complete All Information 1st Adult First Name___________________ MI_____ Last Name_________________________________ Today’s Date___________ Gender: ___M ___F Date of Birth_________________ Marital Status: Single Married Divorced Separated Home/Mailing Address:_________________________________________________________________________________ City_________________________________ State______________ Zip_________ Home Phone_____________________ Employer____________________________________________ Work Phone_____________________________________ Employer Address___________________________________ City____________________ State _______ Zip_________ Home E-Mail__________________________________________ Work E-Mail______________________________________ Emergency Contact____________________________________________ Phone#__________________________________ 2nd Adult First Name___________________ MI_____ Last Name_________________________________ Today’s Date___________ Gender: ___M ___F Date of Birth_________________ Marital Status: Single Married Divorced Separated Home/Mailing Address:_________________________________________________________________________________ City_________________________________ State______________ Zip_________ Home Phone_____________________ Employer____________________________________________ Work Phone_____________________________________ Employer Address___________________________________ City____________________ State _______ Zip_________ Home E-Mail__________________________________________ Work E-Mail______________________________________ Emergency Contact____________________________________________ Phone#__________________________________ Dependants First Name MI Last Name Date of Birth Gender School __________________ ___ ______________________ _______________ _______ _______________________ __________________ ___ ______________________ _______________ _______ _______________________ __________________ ___ ______________________ _______________ _______ _______________________ __________________ ___ ______________________ _______________ _______ _______________________ |
