Membership Application
Membership Type
*
Family
Adult
Rural Family
Rural Adult
Joint Family
Joint Adult
Student
Youth
Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Please enter a valid phone number.
Email
*
example@example.com
Date of Birth
*
-
Month
-
Day
Year
Date
Gender
*
Please Select
Female
Male
Prefer not to answer
Employer
Emergency Contact Information
Name
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Relationship
*
By signing below, I agree to the terms and conditions below, as well as all waivers and release of liability, also outlined below. The Y is the nation’s leading non-profit strengthening communities through youth development, healthy living and social responsibility. Important to the effort is our ability to provide a safe and threat-free environment. For this reason, the Y monitors sexual offender registries. Persons on the list will not be eligible for membership, program participation, volunteer or employment opportunities at the YMCA of West Central Illinois Association. Fees are non-refundable and non-transferable. The Y reserves the right to cancel a membership at any time. Any member, guest, or applicant whose actions are not deemed to be in the best interests of the organization may have their membership or application denied. It is important for you to check your statements regularly. If you notice a discrepancy in your bank draft, please notify us promptly. Refunds are not issued for discrepancies longer than 90 days. Annual memberships are non-refundable. WAIVERS AND RELEASE OF LIABILITYI hereby, for myself, my household, my family, heirs, executors, and administrators, waive and release any and all claims and damages I may have against the Mt. Sterling Community Center YMCA (YMCA) and their respective agents, representatives, successors, and assigns, for any and all injuries which may be suffered by me, my household, or my family in connection in participation in YMCA activities and programs. I understand that the YMCA assumes no responsibility for injuries or illnesses which I, my household or family may sustain as a result of our physical condition, or resulting from our observation or participation in a any activity or use of facilities or equipment used for YMCA activities. I expressly acknowledge on behalf of myself and my heirs that I assume the risk for any and all injuries and illnesses for myself, household, or family which may result from participation in these activities. I also grant full permission to the YMCA to use, without limitation, photographs, film footage or tape recordings which may include the applicant(s) image or voice for purposes of promoting or interpreting YMCA programs. The YMCA conducts regular sex offender screenings on all members, participants, and guests. If a sex offender match occurs, the YMCA reserves the right to cancel membership, end program participation, and remove visitation access. By participating in the YMCA Nationwide Membership Program, I agree to release the National Council of Young Men’s Christian Associations of the United States of America, and its independent and autonomous member associations in the United States and Puerto Rico, from claims of negligence for bodily injury or death in connection with the use of YMCA facilities, and from any liability for other claims, including loss of property, to the fullest extent of the law. I agree to adhere to the YMCA policies and procedures and understand that my guest privilege will be revoked for exhibiting inappropriate behavior including but not limited to cursing, fighting, abuse of facility staff, theft or other criminal acts, overly affectionate displays and dishonesty. I also understand that my/our membership can be revoked without refund for exhibiting inappropriate behavior or abuse toward the YMCA staff and/or facilities. I understand that membership cards remain the property of the YMCA and must be surrendered upon cancellation of membership. In order to replace a lost or damaged card, I am responsible for payment of the current replacement fee. I understand that in order to cancel my membership I must provide written 30-days notice.
*
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Household Members
For family memberships only
Household Member 1
Household Member 2
Household Member 3
Household Member 4
Household Member 5
Household Member 6
Household Member 7
Household Member 8
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Payment Information
Will you be using Dot Foods payroll deduct to pay for your monthly membership?
*
Yes
No
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Payroll Deduct Authorization
Payroll Change
*
New membership
Change in membership type
Name on YMCA Membership
*
First Name
Last Name
Dot/DTI Employee Number
*
Department
*
Job Title
*
Membership Type
*
Adult ($30 - $5 = $25)
Family ($46.50 - $5 = $41.50)
Joint Adult ($39.75 - $5 = $34.75)
Joint Family ($64.50 - $5 = $59.50)
Rural Adult ($30 - $5 = $25)
Rural Family ($46.50 - $5 = $41.50)
Student ($22 - $5 = $17)
By signing below, I hereby authorize Dot Foods to deduct the above listed amount from my paycheck per their guidelines. I understand that my employer will forward my membership fees to the YMCA on my behalf. I understand that if I choose to cancel my membership, I must give 30 days written notice to both my Human Resources Department at my place of employment, as well as the YMCA.
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Payment Authorization Form
Name on YMCA Membership
*
First Name
Last Name
Home Address Tied to Account
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Payment Type
*
Checking
Savings
Debit Card
Credit Card
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Checking or Savings Account
Routing Number
*
Account Number
*
Name as it appears on bank account
*
First Name
Last Name
By signing below, I (We) authorize and request the Mt. Sterling Community Center YMCA to charge my (our) checking/savings or credit card account for my (our) monthly fee. I (We) further authorize the financial institution to process these fees. I (We) understand fees are non-refundable and non-transferable. I (We) understand charges are continuous. If, for any reason, a payment is not honored by the financial institution, a service fee will be charged on any returned transaction. I realize I am still responsible for my payment including the service fee applied by the YMCA for each return incurred. This is in addition to any service fee my (our) financial institution may charge. The YMCA will resubmit a returned payment automatically and will notify me (us) with any issues. Two or more returns could result in termination of service. I (We) understand charges are continuous and it is my (our) responsibility to notify the YMCA in person to discontinue my (our) services and automatic payments. I (We) understand termination requests must be submitted in writing 30 days prior to my (our) next draft date. If I (We) notice a discrepancy on my (our) statement, I (we) will notify the YMCA promptly. I (We) understand refunds are not issued for discrepancies 90 days or more. The Y reserves the right to discontinue service at any time. Any member, guest, or applicant whose actions are not deemed to be in the best interests of the organization may have their membership or application denied.
*
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Debit or Credit Card
Card Number
*
Card Expiration
*
Name as it appears on card
*
First Name
Last Name
Type
*
Mastercard
Visa
Discover
By signing below, I (We) authorize and request the Mt. Sterling Community Center YMCA to charge my (our) checking/savings or credit card account for my (our) monthly fee. I (We) further authorize the financial institution to process these fees. I (We) understand fees are non-refundable and non-transferable. I (We) understand charges are continuous. If, for any reason, a payment is not honored by the financial institution, a service fee will be charged on any returned transaction. I realize I am still responsible for my payment including the service fee applied by the YMCA for each return incurred. This is in addition to any service fee my (our) financial institution may charge. The YMCA will resubmit a returned payment automatically and will notify me (us) with any issues. Two or more returns could result in termination of service. I (We) understand charges are continuous and it is my (our) responsibility to notify the YMCA in person to discontinue my (our) services and automatic payments. I (We) understand termination requests must be submitted in writing 30 days prior to my (our) next draft date. If I (We) notice a discrepancy on my (our) statement, I (we) will notify the YMCA promptly. I (We) understand refunds are not issued for discrepancies 90 days or more. The Y reserves the right to discontinue service at any time. Any member, guest, or applicant whose actions are not deemed to be in the best interests of the organization may have their membership or application denied.
*
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