2023 Membership Registration Form (Paid In Full)

2023 Membership Registration Form (Paid In Full)

11500 Sherburne Ave. Becker MN 55308 763-200-4271
Main Member*

First Name Last Name
Date of Birth*

MonthDay Year
Date
Address*

Mailing Address

Permanent Address

City State

Zip Code
Email
example@example.com
Phone Number*
Cell Number
Emergency Contact*

First Name Last Name
Emergency Contact Phone Number*
Please enter a valid phone number.
Were you referred to the BCC by anyone?
Spouse Name

First Name Last Name
Date of Birth

MonthDay Year
Date
Phone Number
Email
example@example.com
Child Name

First Name Last Name
Date of Birth

MonthDay Year
Date
Child Name

First Name Last Name
Date of Birth

MonthDay Year
Date
Child Name

First Name Last Name
Date of Birth

MonthDay Year
Date
Child Name

First Name Last Name
Date of Birth

MonthDay Year
Date
Child Name

First Name Last Name
Date of Birth

MonthDay Year
Date
Family Emergency Contact

First Name Last Name
Family Emergency Contact Phone Number
Please enter a valid phone number.
ADMINISTRATIVE FEE - $50.00

Upon joining, new members pay an Administrative Fee in addition to Membership dues. Members who allow their memberships to lapse will pay the Administrative Fee in full to re-activate a membership. This Administrative Fee is non-refundable.
Membership Categories: A Family Membership is a husband and wife, or significant other, and their children, with the same permanent address. Once a child reaches the age of 22 years, they are not longer eligible to be on the Family Membership. A Dual Membership is a husband and wife or significant other with the same permanent address.

Seniors: 62 years and older Youth: Under 18 years Adults: 18 years old and older.
REGULAR OR RESDIENT RATE*

Resident: Resides within the Becker City Limits.Regular: Resides outside of the Becker City Limits or lives in Becker Township.
ONE MONTH MEMBERSHIP - (REGULAR OR RESIDENT)

Youth /Senior - $80.07Adult - $97.30Family - $129.56
QUARTER MEMBERSHIP - PAID IN FULL

Youth/Senior Resident - $99.04Adult Resident - $172.42Family Resident - $259.11Youth/Senior Regular - $154.07Adult Regular - $227.43Family Regular - $325.42
ANNUAL MEMBERSHIP - PAID IN FULL

Youth/Senior Resident-$217.91Adult Resident -$354.00Dual Resident-$450.83Family Resident-$518.21Youth/Senior Regular-$324.00Adult Regular-$443.00Dual Regular-$564.83Family Regular-$650.83
These prices do not include tax. Prices subject to change!
UPON JOINING, NEW MEMBERS PAY AN ADMINISTRATIVE FEE IN ADDITION TO MEMBERSHIP DUES. MEMBERS WHO ALLOW THEIR MEMBERSHIPS TO LAPSE WILL PAY THE ADMINISTRATIVE FEE IN FULL,TO RE-ACTIVATE THEIR MEMBERSHIP.*

$50.00 ADMIN. FEE
*PAYMENT MUST BE RECEIVED BEFORE MEMBERSHIP IS ACTIVATED. WE WILL CONTACT YOU TO TAKE CARE OF PAYMENT ONCE WE RECEIVE YOUR MEMBERSHIP APPLICATION.
By purchasing this membeship to the Becker Community Center and signing below, I agree to release the Becker Community Center, City of Becker, their employees and leaders of all liability related to accidents or injuries that myself or members of my family might incur while using the facility or participating in programs and activities. Participants utilizing the facility are not covered under the Becker Community Center’s or the City of Becker’s medical insurance policy. We strongly urge each person to seek a physician’s advice before beginning an exercise program or a program involving physical activity.

The City of Becker and/or the Becker Community Center occasionally photograph activities throughout the facility with the intent to use these images for City publications and communications. We generally take group shots and take cautionary steps to minimize identifying information.
Signature*

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Date*

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Date
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