Private Locker Request Form

Private Locker Request Form
Please note: This form must be completed by a person listed on the membership and submitted to the Centennial Fitness Center 7-days prior to the 1st of the month. Please note, once charges are posted to account they will not be refunded. All annual memberships, induding the All Access upgrade, cannot be cancelled within the first 12 active months unless it is due to medical reasons or proof of relocation. All annual memberships cancelled within the first 12 months are subject to a $35 cancellation fee unless proof of relocation or medical reasons.

Must have a current annual membership and be over 18yrs old to access the private locker room. No exceptions.
Date Submitted:

MonthDayYear
Date
Date of Birth:

MonthDayYear
Date
Member Name:

First NameLast Name
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Current Phone #:
Format: (000) 000-0000.
Current Email:
example@example.com
Membership Type:
Payment Information (please check)
Locker #
*Please submit an EFT/CC authorization form and attach voided check to begin deductions from bank account.
PAYMENT INFORMATION:
Amount
Please enter the last four digits of the credit card currently on file which you would like us to use for your Private Locker Room.
Authorized Signature:
►AUTHORIZATION
I understand by submitting this request I acknowledge and agree this acts as an amendment of my membership agreement. I understand I am responsible for all accrued dues and other charges for which I may be liable and authorize the Park District to modify my account and assess fees as necessary to process this request. I understand and agree to abide by the Park Ridge Park District Centennial Fitness Center Policies. I have verified the above information is correct.
Member Signature:
Should be Empty:

Private Locker Request Form

Payment Information (please check)

►AUTHORIZATION