Fixed Term Membership

MEMBER INFORMATION

Primary account contact.
First Name *
Last Name *
Date Of Birth *

Month Day Year
Date
GENDER *

Male Female Other
EMAIL ADDRESS

By providing your email address, you will receive news letters and occasional updates from the Excelsior Springs Community Center.
Email
example@example.com
RESIDENCE ADDRESS
Street *
City *
State *
Zip *
Phone Number
Phone Number Confirmed *
(###) ### - ####
EMERGENCY CONTACT INFORMATION
Name of Emergency Contact
Relationship
Contact Phone Number

HOUSEHOLD INFORMATION

List additional members if applicable. Family memberships limited to a spouses and dependent children living in the same house. The children must be under age 25. Families with more than 4 children may be asked to provide a 1040 tax return for proof that the children are all claimed on taxes. Adults may be asked to provide proof of residency.
Additional Member #1
Gender
Date of Birth

Month Day Year
Date
Relationship
Additional Member #2
Gender
Date of birth

Month Day Year
Date
Relationship
Additional Member #3
Gender
Date of Birth

Month Day Year
Date
Relationship
Additional Member #4
Gender
Date of Birth

Month Day Year
Date
Relationship
Additional Member #5
Gender
Date of Birth

Month Day Year
Date
Relationship
Additional Member #6
Gender
Date

Month Day Year
Date
Relationship

PAYMENT INFORMATION

Stop by the front desk to have your first payment processed.
Payment Options:

Credit/Debit Card Checking Account

OPTION 1: CREDIT/DEBIT CARD

I authorize electronic funds transfer from the following credit card for the membership fee. Credit/debit card information will be kept on file for future online transactions.
LAST 4 CREDIT/DEBIT CARD NUMBER
EXPIRATION DATE (MM/YY)
3 DIGIT SECURITY CODE
AUTHORIZATION FOR ELECTRONIC FUNDS TRANSFER OR CREDIT CARD PAYMENT

In order to provide for convenient payments to The Excelsior Springs Community Center, the member authorizes electronic funds transfer (EFT) from specified checking/savings account or credit card in the amount due on or after the date specified. Your bank or credit card statement may reflect a variation of ActiveNet, our software host. In no event shall a revocation of authority be effective with respect to entries the bank honors electronic funds transfer by charging the specified account or when the charge is made to the specified credit card, the funds transfer or charge shall constitute the receipt of payment. Should any electronic transfer or charge not be honored then it is understood that payment is to be made by the member in the amount of said payment. This agreement also allows the Excelsior Springs Community Center to initiate a reversing entry to a member’s account in the event that an error occurs.
Initials *

Click and hold inside of the box to draw your signature. Clear

OPTION 2: CHECKING/SAVING

I authorize electronic funds for transfer from the following bank. There will be a $20 service fee for any returned check.
Account Type

Checking Savings
LAST 4 ACCOUNT NUMBER
ROUTING NUMBER
AUTHORIZATION FOR ELECTRONIC FUNDS TRANSFER OR CREDIT CARD PAYMENT

In order to provide for convenient payments to The Excelsior Springs Community Center, the member authorizes electronic funds transfer (EFT) from specified checking/savings account or credit card in the amount due on or after the date specified. Your bank or credit card statement may reflect a variation of ActiveNet, our software host. In no event shall a revocation of authority be effective with respect to entries the bank honors electronic funds transfer by charging the specified account or when the charge is made to the specified credit card, the funds transfer or charge shall constitute the receipt of payment. Should any electronic transfer or charge not be honored then it is understood that payment is to be made by the member in the amount of said payment. This agreement also allows the Excelsior Springs Community Center to initiate a reversing entry to a member’s account in the event that an error occurs.
Initials *

Click and hold inside of the box to draw your signature. Clear

ACKNOWLEDGEMENTS
WAIVER AND RELEASE OF LIABILITY

All members are urged to obtain a physical examination from a doctor before using pools, exercise equipment or participating in any exercise class or program on their own or led by an Excelsior Springs Community Center employee. All exercise, including the use of the pool, weights and any and all equipment, and apparatus designed for exercising, shall be at the member's sole risk. All members understand that the decision to use this facility, or the selection of exercise programs, methods and types of equipment or pool shall be member's entire responsibility, and Excelsior Springs Community Center shall not be liable to member for any claims, demands, injuries, damages or actions arising due to injury to member's or families’ person or property arising out of or in connection with the use by member or family of the services, facilities, and premises of Excelsior Springs Community Center. The member and their family hereby holds Excelsior Springs Community Center, its officers, agents and employees harmless from all claims which may be brought against them by the member or their family or on member's behalf for any such injuries or claims. Do not sign this agreement before reading it and blank spaces are filled in. The member acknowledges that member has read front and back pages and received a completed copy of this agreement in compliance with federal and state law.
Initials *

Click and hold inside of the box to draw your signature. Clear

SUMMARY
Today's Fee: *
I have read the waiver and release of liability and the authorization agreement on EFT or credit card payment and authorize the payment as stated. Charges will begin when processed by staff (typically 1-5 business days).
Signature *

Click and hold inside of the box to draw your signature. Clear
Date *

Month Day Year
Date
Should be Empty:

FIXED TERM MEMBERSHIP

MEMBER INFORMATION

EMAIL ADDRESS

RESIDENCE ADDRESS

EMERGENCY CONTACT INFORMATION

HOUSEHOLD INFORMATION

PAYMENT INFORMATION

OPTION 1: CREDIT/DEBIT CARD

AUTHORIZATION FOR ELECTRONIC FUNDS TRANSFER OR CREDIT CARD PAYMENT

OPTION 2: CHECKING/SAVING

AUTHORIZATION FOR ELECTRONIC FUNDS TRANSFER OR CREDIT CARD PAYMENT

ACKNOWLEDGEMENTS

WAIVER AND RELEASE OF LIABILITY

SUMMARY