Application Date: ________/________/________

                             Month             Day         Year

 

Name:                                                                                                                                                                                                                                                                                        

                 Last                                                                                              First                                                                            Middle

 

Email address:_________________________

 

Mailing Address:                                                                                                                                                                                                                            

 

City:                                                                                             State:                       Zip:                                                                                                               

 

Phone: (Home)                                                                         (Work):                                                           (Cell):                                                                  

 

Employer:                                                                                                                                                                                                                                          

 

Applicant’s birth date: _____________/_____________/____________     Sex:    M      F

                                                   Month                Day                    Year

Driver’s License number: _____________________________  Exp. Date: ____________________

 

Fill out this section if you are applying for a YMCA Family Membership.  (A family consists of no more than 2 adults residing in the same household and all children 18 years or under or full time students that are dependent upon the same family income.  (Full time status is considered 12 units or more.  Written verification from the school is required to verify full-time status).  All other individuals such as roommates residing in the residence are not considered family members.

 

THE YMCA RESERVES THE RIGHT TO TERMINATE A MEMBERSHIP AT ANY TIME.

 

NAME (please include middle initial)                                  Birthday                                 Age           Relationship 

 

                                                                                        M     F     ______/______/______      _____        ______________________                           

 

                                                                                        M     F     ______/______/______      _____      ______________________________        

 

                                                                                        M     F     ______/______/______      _____      ______________________________        

 

 

Do you have any medical conditions we should be aware of? (circle one)       YES          NO     

If yes, please describe                                                                                ______________________                           

 

In case of an emergency, please notify:

 

Name:                                                                                                           Phone:                                      Relationship:______________________

 

Name:                                                                                                           Phone:                                        Relationship:______________________

 

How did you hear about us?

YMCA Brochure           Friend/Relative/Co-Worker (name)                                                                                                 Telephone Book

Advertisement (Newspaper/Radio)                School                    Other                                                                                                                            

 

The YMCA is one of the county’s largest volunteer organizations.  Do you or anyone in your household have any special interests or talents that you might be willing to share?      Yes________         No_______ 

If yes, what?_______________________________________

 

I hereby apply for membership to the YMCA and agree to abide by all rules, regulations and policies.  I acknowledge that YMCA activities include physical activity and assume all risk in said activities.  The San Luis Obispo County YMCA will not be responsible for lost or stolen articles.  Membership is non-transferable or refundable.

 

Signature:                                                                          Date:                                           

NEW MEMBERSHIP APPLICATION