MEMBERSHIP UPDATE FORM
CHECK ALL CHANGES THAT APPLY:
*
Name/Address
Emergency Contact
Hold Membership or Remove a Hold
Update to Insurance Membership
Membership Type
Add/Remove Members
Renew Membership (Has to be done in person)
Today's Date
*
/
Month
/
Day
Year
Date
First Name
*
Last Name
*
Address
*
Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Phone Number
*
-
Area Code
Phone Number
Email
example@example.com
Membership Type
*
Senior- 3 Months
Youth- One Month
Adult- One Month
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EMERGENCY CONTACT
Name of New Emergency Contact
Relationship
Phone Number
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MEMBERSHIP TYPE
New Membership Type
Adult individual ($40)
Senior Individual ($35)
Teen individual ($30)
Young adult 20-24 ($35)
Couple ($55)
Single w/ kids ($60)
Family ($70)
Package Fee
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UPDATE TO INSURANCE MEMBERSHIP
Insurance Type
Silver Sneakers
Renew Active
Silver&Fit
Insurance Member ID
*
Renew Active Confirmation Number
*
Silver Sneakers Confirmation Number
*
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ADD/REMOVE FAMILY MEMBERS
Dependent #1
Gender
Date of Birth
-
Month
-
Day
Year
Date
Relationship
Spouse
Child
If other please specify
Add or Remove
Add
Remove
Dependent #2
Gender
Date of Birth
-
Month
-
Day
Year
Date
Relationship
Spouse
Child
If other please specify
Add or Remove
Add
Remove
Dependent #3
Gender
Date of Birth
-
Month
-
Day
Year
Date
Relationship
Spouse
Child
Other
If other please specify
Add or Remove
Add
Remove
Dependent #4
Gender
Date of Birth
-
Month
-
Day
Year
Date
Relationship
Spouse
Child
If other please specify
Add or Remove
Add
Remove
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HOLD MEMBERSHIP
Drafts can be held one time for a maximum of three consecutive months per 12-month period. 10 days’ written notice is required to process holds. The membership and fees will be on hold for the months requested and use of the facility is prohibited during that time. Regular membership dues will automatically resume drafting after the hold.
Hold or Remove Hold
*
Hold
Remove Hold
Hold for:
*
January
February
March
April
May
June
July
August
September
October
November
December
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Member Signature
*
Date
*
/
Month
/
Day
Year
Date
Preview PDF
Submit
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