2024 Piedmont Bend Membership Application

2024 Piedmont Bend Recreation Association Application for Membership

Swim Season: Saturday, May 4th - Saturday, September 28th
Primary Contact Information
Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Primary Phone Number*
Please enter a valid phone number.
Alternate Phone Number
Please enter a valid phone number.
Primary Email*
example@example.com
Family Members

List the names and contact information of each family member. Any email address provided will be added to the Piedmont Bend Distribution list, but will otherwise not be shared. *Family member is defined as a person living in the same household and at the same address, and/or legally related to the primary member.
First Name Last Name Email Primary Phone Alternative Phone
First Name Last Name Email Primary Phone Alternative Phone
First Name Last Name Email Primary Phone Alternative Phone
First Name Last Name Email Primary Phone Alternative Phone
First Name Last Name Email Primary Phone Alternative Phone
First Name Last Name Email Primary Phone Alternative Phone
2024 Annual Dues
Select Type of Membership*

Swim & Tennis - $500Social Membership* - $125
*Social Membership provides and limits the member the opportunity to participate in special social events and activities hosted by PBRA only. Membership does not include a key card.
Membership Fee
Discounts or Additional Fees

Participated in Work DayApplication/Payment Submitted after June 1, 2024Need Additional or Replacement Pool Key CardNeed 2nd Additional or Replacement Pool Key Card
Work Day Discount
Late Fee
Additional or Replacement Key
Membership Due*
Key Card Information

Please list your current pool key card number(s) below to ensure that we have the correct number(s) in our database. Key cards will be activated once membership payment is received.*Key card number will be the last 5 digits listed on the card.
Pool Key Card Number (last 5 digits listed on card or N/A for New Member)*
Pool Key Card Number
Pool Key Card Number
Pool Key Card Number
Pool Key Card Number
Pool Key Card Number
Pool Key Card Number
Pool Key Card Number
Membership Agreement

I have read and agree to Piedmont Bend Recreation Association Rules and Regulations, which can be found at piedmontbend.com.
Name*

First NameLast Name
Signature*

Clear
Date*

MonthDayYear
Date
Should be Empty:

2024 Piedmont Bend Recreation Association Application for Membership

Primary Contact Information

Family Members

2024 Annual Dues

Key Card Information

Membership Agreement