2023 Membership Registration Form

Becker Community Center 2023 Membership Registration Form

11500 Sherburne Ave. Becker MN 55308 763-200-4271
(Monthly EFT)
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.
ANNUAL MEMBERSHIP - MONTHLY EFT*

Youth/Senior Resident - $23.16/monthAdult Resident - $34.50/monthDual Resident - $42.57/monthFamily Resident - $48.18/monthYouth/Senior Regular - $32.00/monthAdult Regular - $41.92/monthDual Regular - $52.07/monthFamily Regular - $59.24/month
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
Monthly EFT Agreement and Information

Please read the following and sign below:

* I authorize the Becker Community Center to initiate debit entries to my account as indicated below.

* I understand payments will be taken from this account on the 10th of each month.

* I authorize the Becker Community Center to resubmit any draft that is returned to my bank for any reason.

* I understand that I am fully responsible for the payments due under this agreement. In the event my bank for any reason does not honor a draft I will make payment directly to the Becker Community Center when notified of such event.

* I understand I will be charged a $30.00 return fee if a draft is not honored.

* I understand the Becker Community Center is entitled to cancel my pass in the event monthly payments are not made by the bank or by me.

* I understand this agreement is for a minimum of 12 months. If I cannot fulfill this one- year commitment I will be charged a $50.00 cancellation fee.

* After the initial 12-month period I understand my membership is on a month to month basis and does continue unless the Becker Community Center is notified in writing 30 days in advance of cancellation or change in my pass.

*I understand it is my responsibility to notify the Becker Community Center in writing if I change banks or close my account.

*I understand prices are subject to change upon notification.
Signature*

Clear
*PAYMENT MUST BE RECEIVED BEFORE MEMBERSHIP IS ACTIVATED. WE WILL CONTACT YOU TO TAKE CARE OF PAYMENT ONCE WE RECEIVE YOUR MEMBERSHIP APPLICATION. ADDITIONAL BANK ACCOUNT/CREDIT OR DEBIT CARD ACCOUNT INFORMATION FORMS WILL NEED TO BE COMPLETED TO COMPLETE MEMBERSHIP. THESE FORMS ARE AVAILABLE TO BE PRINTED FROM THE BCC WEBSITE, UNDER FORMS/PRINTABLE FORMS, OR ARE AVAILABLE AT THE BCC FRONT DESK.

*MEMBERSHIP IS NOT VALID UNTIL ALL APPLICABLE FORMS HAVE BEEN COMPLETED BY MEMBER*
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*

Clear
Date*

MonthDay Year
Date
Should be Empty:

Becker Community Center 2023 Membership Registration Form

(Monthly EFT)