YMCA Employee Membership Application

Primary Member Name

First Middle Last

Primary Member Gender(Required)

Primary Member Birth Date(Required)

Primary Member Phone(Required)

Alternate Phone

Email(Required)

Enter Email Confirm Email

Address(Required)

City(Required)

State(Required)

ZIP(Required)

Emergency Contact Name(Required)

First Last

Emergency Contact Phone(Required)

Are you a current YMCA Member?(Required)

Yes

I am currently a member at this YMCA(Required)

What is the withdrawal date of your membership dues?(Required)

Type of Membership(Required)

Individual Membership

Family Membership

Member 2 Name

First Middle Last

Member 2 Relationship(Required)

Member 2 Gender(Required)

Member 2 Birth Date(Required)

Add a 3rd Member

Add a 3rd member

Member 3 Name

First Middle Last

Member 3 Relationship(Required)

Member 3 Gender(Required)

Member 3 Birth Date(Required)

Add a 4th Member

Add a 4th member

Member 4 Name

First Middle Last

Member 4 Relationship(Required)

Member 4 Gender(Required)

Member 4 Birth Date(Required)

Add a 5th Member

Add a 5th member

Member 5 Name

First Middle Last

Member 5 Relationship(Required)

Member 5 Gender(Required)

Member 5 Birth Date(Required)

Add a 6th Member

Add a 6th member

Member 6 Name

First Middle Last

Member 6 Relationship(Required)

Member 6 Gender(Required)

Member 6 Birth Date(Required)

Add a 7th Member

Add a 7th member

Member 7 Name

First Middle Last

Member 7 Relationship(Required)

Member 7 Gender(Required)

Member 7 Birth Date(Required)

Add a 8th Member

Add a 8th member

Member 8 Name

First Middle Last

Member 8 Relationship(Required)

Member 8 Gender(Required)

Member 8 Birth Date(Required)

Additional Member Information(Required)

RELEASE AND WAIVER OF LIABILITY AND INDEMNITY AGREEMENT(Required)

RELEASE AND WAIVER OF LIABILITY AND INDEMNITY AGREEMENT

IN CONSIDERATION FOR PROGRAMS AND ACTIVITIES of the YMCA for any purpose, including, but not limited to observation or use of facilities or equipment, or participation in and off-site program affiliated with the YMCA, the undersigned, for himself or herself and any personal representatives, heirs, and next of kin, hereby acknowledges, agrees and represents that he or she has, immediately upon entering or participating inspected and carefully considered such premises and facilities or the affiliated programs. It is further warranted that such entry into the YMCA for observation or use of any facilities or equipment or participation in such affiliated program constitutes an acknowledgement that such premises and all facilities and equipment thereon and such affiliated program have been inspected and carefully considered and that the undersigned finds and accepts same as being safe and reasonably suited for the purpose of such observation, use or participation.

IN FURTHER CONSIDERATION OF BEING PERMITTED TO ENTER THE YMCA FOR ANY PURPOSE INCLUDING, BUT NOT LIMITED TO OBSERVATION OR USE OF FACILITIES OR EQUIPMENT, OR PARTICIPATION IN ANY OFF-SITE PROGRAM AFFILIATED WITH THE YMCA, THE UNDERSIGNED HEREBY AGREES TO THE FOLLOWING:

1. THE UNDERSIGNED HEREBY RELEASES, WAIVES, DISCHARGES AND COVENANTS NOT TO SUE the YMCA and all branches thereof, its directors, officers, employees, and agents (hereinafter referred to as “releasees”) from all liability to the undersigned, its personal representatives, assigns, heirs, and next of kin for any loss or damages, and any claim or demands therefore on account of injury to the person or property or resulting in death of the undersigned, whether caused by the negligence of the releasees or otherwise while the undersigned is in, upon, or about the premises or any facilities or equipment therein or participating in any program affiliated with the YMCA.
2. THE UNDERSIGNED HEREBY AGREES TO INDEMNIFY AND SAVE AND HOLD HARMLESS the releasees and each of them from any loss, liability, damage or cost they may incur due to the presence of the undersigned in, upon or about the Family YMCA premises or in any way observing or using any facilities or equipment of the YMCA or participating in any programs affiliated with the Family YMCA whether caused by the negligence of the releasees or otherwise.
3. THE UNDERSIGNED HEREBY ASSUMES FULL RESPONSIBILITY FOR AND RISK OF BODILY INJURY, DEATH OR PROPERTY DAMAGE due to negligence of releasee or otherwise while in, about, or upon the premises of the YMCA and/or while using the premises or any facilities or equipment thereon or participating in any program affiliated with the YMCA.

I hereby grant permission for the staff of the YMCA to take whatever steps necessary to obtain medical care for my child if warranted. These steps include the following: (1) To administer First Aid; (2) To contact parent/guardian or person listed on emergency contact. If necessary, an ambulance will be called to transport the child to an emergency medical center. I understand that I will be held responsible for all medical/ambulance charges.

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 & Puerto Rico, from claims of 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.

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.

Cross Branch Utilization: Members of Crossroads YMCA are welcome to visit any branch within the association. We ask that 50% of your membership unit’s total monthly visits be to your primary branch (the branch that collects your membership dues).

THE UNDERSIGNED HAS READ AND VOLUNTARILY SIGNS THE RELEASE AND WAIVER OF LIABILITY AND INDEMNITY AGREEMENT, and further agrees that no oral representations, statements or inducement apart from the foregoing written agreement have been made.

I HAVE READ AND UNDERSTAND THE RELEASE AND WAIVER OF LIABILITY AND INDEMNITY AGREEMENT

PHOTO/WEBSITE/FACEBOOK RELEASE(Required)

For my participation in activities to be conducted by the Crossroads YMCA, I hereby give my permission and consent, now and for all time, to Crossroads YMCA, to make, reproduce, edit, broadcast or rebroadcast any video film, footage, sound track recordings and photo reproductions of me and/or my children. I understand that my experience within said activities may be used for advertising in Crossroads YMCA, brochure, Facebook account or Website without any compensation to, and/or claim, by me. I may, or may not be, identified in such reproductions; however, any minor if identified will only be by first name or initial only.

Any video film, recordings, and photo reproductions of me and/or my family experience during said activities, I authorize, according to this Release, shall belong to Crossroads YMCA therefore, we will have full right of disposition of any video film, footage, sound track recordings and photo reproductions of me and/or my family.
Crossroads YMCA and collaborating third parties shall not be liable for any use or disclosure to a third party of any video film, footage, recordings and photo reproductions of me and/or families account of our experience.
I agree that I am 18 years of age or older and my consent and this release are irrevocable. I hereby release and discharge Crossroads YMCA and collaborating third parties from any and all claims in connection with the uses and reproductions of any video film, footage, sound track recordings and photo reproductions of me and/or my families’ narrative account of our experience as described herein.

I HAVE READ AND UNDERSTAND THE PHOTO/WEBSITE/FACEBOOK RELEASE

PAYROLL DEDUCTION AGREEMENT(Required)

I acknowledge and provide my consent as indicated by my initials that monthly membership drafts are continual until 30-days written notice is given. This cancellation notice can be done in person at any branch or online through the Crossroads YMCA website.

I acknowledge and provide my consent as indicated by my initials that monthly membership fees may periodically increase. Notification will be given via email prior to any rate increase.

I acknowledge and provide my consent as indicated by my initials that my membership rate could increase if due to my age, my membership type changes. Notification will be given via email prior to any change in membership type and rate increase.

I acknowledge and provide my consent as indicated by my initials that if I hold a family membership a $15.00 per person fee will be added to my membership when a third or more additional adult turns 25 years of age. Notification will be given via email prior to any additional fee added to membership.

I acknowledge that upon receiving notification of any fee increase to my membership, if I do not want to have an increase go into effect, I may choose to cancel my membership (as detailed above) or inactivate additional family membership adult(s) with 30-days notice.

I acknowledge and provide consent as indicated by my initials that returned drafts may be collected electronically by a third party with a $25 processing fee assessed in addition to any fees charged by my bank.

I hereby authorize my employer to deduct from my wages for my/my family’s Crossroads YMCA membership monthly, beginning with my paycheck after the below date.

Upon separation of employment for any reason or if I am not receiving a paycheck for any reason, I understand that it is my responsibility to notify the YMCA that I wish to continue my/my family’s YMCA membership and to make alternative payment arrangements. I understand that my employer will notify the YMCA that they will no longer be forwarding my YMCA membership dues and that my failure to notify the YMCA and make alternative payment arrangements may result in my YMCA membership being suspended by the YMCA per their rules and regulations.

I further understand that if I decide to cancel my membership at any time or if I no longer wish to have money deducted from my pay, I will not receive any refund of money deducted regardless of when I notify my employer. In other words, there will be no pro-ration of the monthly membership fee regardless of when I cancel or notify my employer of my desire to stop payroll deductions.

I HAVE READ AND UNDERSTAND THE PAYROLL DEDUCTION AGREEMENT

Please provide your initials here to indicate your acceptance of the above terms.(Required)

Signature(Required)

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ADMIN USE Primary Member First Name(Required)

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ADMIN USE Primary Member Middle Name

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ADMIN USE Primary Member Last Name(Required)

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