The Silver Falls Family YMCA
We
build strong kids, strong families, and strong communities.
MEMBERSHIP APPLICATION
Please Print: Cost $35.00/year.
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Last Name
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First Name |
Initial |
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Address
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City
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State |
Zip |
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Home Phone
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Work Phone |
Date of Birth |
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Family Email Address: (print carefully to be exact)
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How did you hear about the YMCA? |
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Employer
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Spouse Employer
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Family Members to be Included with this Membership
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Spouse First Name
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Last Name |
M. I. |
M or F |
Relationship |
Date of Birth |
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Child’s First Name
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Last Name |
M. I. |
M or F |
Relationship |
Date of Birth |
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Child’s First Name
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Last Name |
M. I. |
M or F |
Relationship |
Date of Birth |
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Child’s First Name
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Last Name |
M. I. |
M or F |
Relationship |
Date of Birth |
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Child’s First Name
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Last Name |
M. I. |
M or F |
Relationship |
Date of Birth |
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Child’s First Name
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Last Name |
M. I. |
M or F |
Relationship |
Date of Birth |
Emergency Contact Information
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Family Doctor
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Doctor’s Phone Number |
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Hospital Preference
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Ambulance Preference |
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Emergency Contact
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Phone Number ---------------------------------------------------- Alternate Phone |
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This application indicates my approval that, in the event of my sickness, the Silver Falls Family YMCA has my authorization under emergency conditions to secure, at my expense, such medical attention as deemed necessary if unable to communicate with me directly. I understand that any photos of myself and/or my family members may be used for publicity purposes. Also, I understand that the Silver Falls Family YMCA does not carry accident or health insurance and that I am participating in all activities at my own risk.
The basic objective of the silver Falls Family YMCA is to aid in the development of Christian standards of living, conduct and life purpose of its members and constituency. In the attainment of this goal, the Association seeks to promote the physical, mental, social, and spiritual growth of persons, to emphasize reverence for God, development of leadership, responsibility for the common good, respect for personality and the application of the Golden Rule in human relationships.
I hereby agree to observe the rules and policies of the Silver Falls Family YMCA and to submit the necessary membership dues to remain a member in good standing.
Signature: ___________________________________________________ Date: ___________________________