EAST COUNTY FAMILY YMCA MEMBERSHIP REGISTRATION FORM PLEASE PRINT AND COMPLETE IN FULL:


Billing Member / Legal Guardian Last Name__________________________________First Name_______________________________Birthdate____/____/____ Address________________________________________________________________________________ ! Male ! Female City______________________State______Zip________Home Phone ( Cell Phone (


)____________Business Phone (


Emergency Contact_____________________________________________________Phone( Employer ___________________________________________________________


)____________


)______________________E-Mail Address______________________________________________________ )________________________


Please list all family members included on membership. Family memberships cover children 21 yrs and under. 1._______________Birthdate___/___/___ ! Male ! Female 4.________________Birthdate___/___/___ ! Male ! Female 2._______________Birthdate___/___/___ ! Male ! Female 5.________________Birthdate___/___/___ ! Male ! Female 3._______________Birthdate___/___/___ ! Male ! Female 6.________________Birthdate___/___/___ ! Male ! Female Spouse_________________________________ Cell Phone (


)____________________ Birthdate ____/____/____


Automatic Draft Authorization: I (We) hereby authorize the YMCA of San Diego County, herein called the YMCA, to initiate debits to the account indicated below, hereinafter called ACCOUNT, to debit the amounts thereof to my account (our checking or credit account indicated below).


Please Initial______________ Account #_______________________________________________ Exp Date_____________


Please Initial______________This authority is to remain in full force and effect until the YMCA has received written notification and the return of my membership card [15] days prior to draft date, or until the YMCA has sent 15-day notification to me regarding termination of this agreement.


Please Initial______________I understand that bank drafts occur on the 10th or 25th and credit card drafts occur on the 15th , and it’s my responsibility to check my monthly bank/credit card statement and report any corrections immediately to the YMCA.


Please Initial______________I understand that changes to my checking or credit card account require written notification to the YMCA at least 15 days prior to my draft date. And it is my responsibility to verify that my cancellation notification has been received by the YMCA and to verify my monthly bank statement.


Please Initial______________I understand that all returned checks, non-sufficient funds, account closed and/or account frozen will automatically incur a $15.00 service fee.


Please Initial______________I understand there are no refunds given. [Cancellation of membership cannot be made until joiners fee is completely paid.]


Please Initial______________I have received the YMCA New Member packet and it is my responsibility to go through all the information in it, including the refund policy and YMCA Code of Conduct.


Please Initial______________Replacement of cards is $10.00, if my card is lost or misplaced.


Please Initial______________I understand that my YMCA membership is not held for short-term illness or vacation. I also understand that the YMCA does not provide accident or medical insurance. To my knowledge, I am in good health, and use these facilities at my own risk.


Signature_____________________________________________ Staff Signature_____________________________________ Date


Date


Interest Information !Active Older Adults !Aerobics !Aquatics !Camps !Childcare !Dance !Family Events !Fitness !Gymnastics/Cheer !Lap / Master’s Swim !Martial Arts !PeeWee Sports !Personal Training !Pilates / Gravity !Sports Leagues !Studio Cycling !Teen Programs !Yoga !Other______________


How did you hear


about us? !Direct Mail !Newspaper !Website !Guest of a Member !Returning Member !Word of Mouth !Street Display !Email !Other


YMCA OF SAN DIEGO COUNTY MEMBER/PARTICIPANT ETHNICITY TRACKING TOOL (OPTIONAL): This voluntary information will be used for statistical purposes in order to enable our YMCA to provide quality services to our community members.


! White/Caucasian


! Native American Indian PRIMARY LANGUAGE


! Black/African American ! Multi Cultural


! English ! Spanish ! Hispanic/Latino ! Asian/Pacific Islander ! Other______________________ See reverse side of this page to complete registration form. 36 La Mesa 619.464.9622 Santee 619.449.9622 Rancho San Diego 619.462.9622 www.eastcounty.ymca.org


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