Membership Application
Preferred Prefix
Mr.
Mrs.
Ms.
Other
Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date Picker Icon
Age
Gender
*
Male
Female
Non-binary
Other
Email
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
What number did you provide?
*
Cell
Home
Other
You may agree or disagree to this statement: By providing your cell phone number, you agree to receive text messages from Lakeshore Foundation related to conversational, membership and account information, promotional events or offers, appointment reminders and other Lakeshore Foundation related topics at the phone number provided above. You may reply STOP to opt-out at any time. Reply HELP for assistance. Messages and data rates may apply. Message frequency will vary. Learn more on our Privacy Policy Page (https://www.lakeshore.org/terms-privacy/) and SMS Terms and Conditions(https://www.lakeshore.org/wp-content/uploads/2025/10/SMS-Terms-and-Conditions-FINAL1_A.pdf).
Please Select
I Agree
I Do Not Agree
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
What county do you live in?
*
Bibb
Blount
Chilton
Cullman
Fayette
Jefferson
Shelby
St. Clair
Talladega
Tuscaloosa
Out of State
Other
Referred By
Member
Physician
Staff
Educator
PT/Therapist
Other
Name of Referral Source
Race/Ethnicity
*
Asian/Pacific Islander
Black/African American
Hispanic/Latino
White/Caucasian
Native American
Other
Emergency Contact Name
*
Emergency Contact Relation
*
Emergency Contact Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Are you a Veteran or Active Service member?
*
Yes
No
What branch did you serve in?
Please Select
Air Force
Army
Coast Guard
Marine Corps
Navy
Space Force
Number of Years Served
Do you have a service-connected physical disability?
Yes
No
Please upload ONE of the following: DD-214, current Military ID, or AL Drivers License WITH Veteran status. (If you are completing this form in person at Lakeshore, you do not need to do this.)
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Please provide a brief narrative explaining/describing your military service/experience.
Ex. I served in the US Army from 1996-2022, separating with an Honorable discharge at the rank of E5. I served at Fort Hood in the First Armored Division.
Provide a brief description of what type of activity you are interested in that Lakeshore provides.
Are you employed?
*
Employed
Retired
Not Employed
Employed By
Retired From
Will you be using any insurance benefits toward your membership?
*
Yes
No
I'm not sure if I have insurance benefits to use.
Member Eligibility Code - Contact your insurance provider for this code. Renew Active codes will begin with the letter "A" or "S" followed by 9 numbers.
Renew Active Code
Member Eligibility Code - Contact your insurance provider for this code. Silver Sneakers codes are 16 digits long and typically begin with "2300-".
Silver Sneakers Code
Primary Disability or Health Condition
*
Secondary Health Condition
*
Treating Physician (Name)
Treating Physician's Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Treating Physician's Clinic Name
Membership Package Options
Please note that all applications are reviewed to ensure members meet eligibility requirements.
Please choose the membership type you are wanting.
*
Standard - $55/month - Access to Lakeshore facility, classes and programs, excluding the Aquatics Center & aquatics classes
Premier - $70/month - Access to Lakeshore facility, classes and programs, including the Aquatics Center & aquatics classes
Youth or Rostered Athlete - $60/month - Access to Lakeshore facility, classes and programs, including the Aquatics Center & aquatics classes
Additional Individuals on Membership
Household members may be added: $25/adult, $20/child monthly - Proof of residency for all members is required.
Would you like to add any additional members?
*
Yes
No
How many family/household members will be joining with you?
*
Please do not include yourself in this number. For requests larger than six (6) members, please contact the front desk directly.
Family Member #1
Name
First Name
Last Name
Birth Date
-
Month
-
Day
Year
Date Picker Icon
Qualifying Condition (if applicable)
What is your relationship to this person?
Family Member #2
Name
First Name
Last Name
Birth Date
-
Month
-
Day
Year
Date Picker Icon
Qualifying Condition (if applicable)
What is your relationship to this person?
Family Member #3
Name
First Name
Last Name
Birth Date
-
Month
-
Day
Year
Date Picker Icon
Qualifying Condition (if applicable)
What is your relationship to this person?
Family Member #4
Name
First Name
Last Name
Birth Date
-
Month
-
Day
Year
Date Picker Icon
Qualifying Condition (if applicable)
What is your relationship to this person?
Family Member #5
Name
First Name
Last Name
Birth Date
-
Month
-
Day
Year
Date Picker Icon
Qualifying Condition (if applicable)
What is your relationship to this person?
Family Member #6
Name
First Name
Last Name
Birth Date
-
Month
-
Day
Year
Date Picker Icon
Qualifying Condition (if applicable)
What is your relationship to this person?
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