• FIXED TERM MEMBERSHIP

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  • MEMBER INFORMATION

    Primary account contact.
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  • EMAIL ADDRESS

    By providing your email address, you will receive news letters and occasional updates from the Excelsior Springs Community Center.
  • RESIDENCE ADDRESS

  • EMERGENCY CONTACT INFORMATION

  • 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.
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  • 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.
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  • 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.

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  • SUMMARY

  • 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. 

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