Trial Membership Application Form

Trial Membership Application

During your 2 week paid Trial, enjoy access to the facility including our Lap Swim, Group Fitness, Wellness Center, Gymnasium, Kids’ Club, and Outdoor Center.
Name *

First Name Last Name
Date of Birth *

Month Day Year
Date
Please choose the item that best describes your YMCA status: *
Trial Membership Type *

2 Week Adult - $23 2 Week Senior - $17 2 Week Senior Couple - $26 2 Week Family - $37
Preferred Start Date

Month Day Year
Date
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
E-mail *
example@example.com
Phone *
Emergency Contact *

First Name Last Name
Emergency Contact Phone Number *
Please enter a valid phone number.
Additional Family Member

First Name Last Name
Date of Birth

Month Day Year
Date
Additional Family Member

First Name Last Name
Date of Birth

Month Day Year
Date
Additional Family Member

First Name Last Name
Date of Birth

Month Day Year
Date
Signature

Clear
Signature Date *

Month Day Year
Date
Should be Empty: