IACC Membership Application with Payment

Membership Application

To apply for membership please complete all the questions below.
Primary Member Information
Name *

First Name Last Name
Date of Birth *

Month Day Year
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Primary Email *
example@example.com
Phone Number *
Please add a primary phone number
Phone Type *
What kind of a phone line is it?
Secondary Member Information
Name

First Name Last Name
Date of Birth

Month Day Year
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Email
example@example.com
Phone Number
Please enter a valid phone number.
Phone Type
What kind of phone line is it?
Dependent Children Information

Dependent children are children under the age of 21 years old.
Name

First Name Last Name
Date of Birth

Month Day Year
Name

First Name Last Name
Date of Birth

Month Day Year
Name

First Name Last Name
Date of Birth

Month Day Year
Name

First Name Last Name
Date of Birth

Month Day Year
How would you like to receive your monthly newsletter? *
Printed versions will only be sent to primary members.
Terms & Conditions

General

The IACC reserves the right to adjust membership dues and benefits at their discretion. All members will receive a 30-day notice prior to any such change. Membership can and will be terminated at any time for non-payment of dues and membership code of conduct violations.

Liability Release

I hereby assume full responsibility for all damages, injuries, or losses that I, any member of my household, or my guests may sustain or incur while on or near the IACC or the IACC Foundation premises. I hereby waive all claims or damages that I, any member of my household, or my guests may sustain.

Photo Release

I hereby grant the Italian American Community Center, the Italian American Community Center Foundation, their officers and employees the right to take photographs and video of myself, members of my household, and my guest, along with our perspective property in connection with the IACC and The IACC Foundation. I agree that the IACC & the IACC Foundation may use photographs and video for any lawful purpose including, but not limited to, publicity, illustrations, advertising and promotion.
Signature *

Clear
Signature Date
Membership Types (all prices includes 3% processing fee)
prev next ( X )
Full Membership with Partner Full Membership with Partner includes full benefits for two adults and includes pool access.
$ 412.00 Quantity

Full Membership Full Membership includes full benefits for one adult and includes pool access.
$ 360.50 Quantity

IACC Membership The IACC Membership includes full benefits for one adult and does not include the use of the pool.
$ 257.50 Quantity

IACC Membership with Partner The IACC Membership with Partner includes full benefits for two adults and does not include the use of the pool.
$ 309.00 Quantity

Pool Membership with Partner The Pool Membership with Partner includes no member benefits except the use of the pool for two adults.
$ 309.00 Quantity

Pool Membership The Pool Membership includes no member benefits except use of the pool for one adult.
$ 257.50 Quantity

Total

$ 0.00
Billing Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
Send Gift?

Yes No
Recipient's Full Name

First Name Last Name
Gift Message
Special Instructions

Payment Methods

Debit or Credit Card

First Name	Last Name
Credit Card Number	Security Code
Card Expiration

Please click one of the PayPal options to complete payment and submit the form.

Should be Empty:

Membership Application

Primary Member Information

Secondary Member Information

Dependent Children Information