Membership Application Form

Full Name

First NameLast Name

Birthday

Date

E-mail:

Phone Number

Format: (000) 000-0000.

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Emergency Contact

First NameLast Name

Emergency Contact Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Primary Adult Employer

Household Members (if family membership)
First Name   Last Name     Birthday
First Name   Last Name     Birthday
First Name   Last Name    Birthday
First Name   Last Name   Birthday

Waivers and Release of Liability by signing below, I agree to the terms and conditions provided on this application. I agree to all waivers and release all liability, also outlined on this application.

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.&#13;&#10;&#13;&#10;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.&#13;&#10;&#13;&#10;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.&#13;&#10;&#13;&#10;WAIVERS AND RELEASE OF LIABILITY&#13;&#10;I 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.&#13;&#10;&#13;&#10;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.&#13;&#10;&#13;&#10;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.&#13;&#10;&#13;&#10;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.&#13;&#10;&#13;&#10;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 &#13;&#10;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&#13;&#10;&#13;&#10;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.&#13;&#10;&#13;&#10;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.&#13;&#10;

Signature

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