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17150 Waterloo Grosse Pointe, MI 48230 Phone: 313.885.4600 Fax: 313.885.2418 Recreation and Wellness Center Membership Application [ ] Annual – Adult [ ] Annual – Adult+1 [ ] Annual – Senior [ ] Annual – Senior +1 Payment Type: [ ] Monthly Electronic Fund Transfer [ ] Annual Family + 2 [ ] Annual Family 3+ [ ] Summer Special [ ] Monthly __________ [ ] Daily ____________ [ ] _________________ [ ] ________________ Primary Applicant: First Name ______________________________ Last Name _________________________________ Address _________________________________ City ___________________________ Zip ________ Home Phone __________________ Cell Phone ____________________ Gender: [ ] Male [ ] Female Birthdate ___________________ Age _______ Email Address __________________________________ Additional Family Members (Complete additional form if more than four dependents living in your household) Name Relationship Gender Spouse/Partner M F Dependent Child M F Dependent Child M F Dependent Child M F Birth Date Issue Date Cost Pass Type Relationship: Dependents age 15 and younger must be a son/daughter or prove dependency on primary applicant. Spouse and dependent(s) with a different last name must provide marriage or birth certificate. Pass Holder Agreement: 1. I understand that participation in any available activity and use of the equipment and facilities within the Neighborhood Club is at my sole discretion and judgment and is at my own risk. I will appropriately and safely limit my activities and those of my dependents, to take into account my/our physical condition. 2. I hereby voluntarily release and hold harmless the Neighborhood Club its officers, agents, and employees from all liability for all types of damages, loss, and injuries, including death, whether foreseeable or not, sustained by myself, and my minor child, and other family members while participating, watching, and traveling to or from the facilities. 3. I understand the attached policies and agree to abide to their terms and conditions. 4. I understand that the membership is for general use of the Neighborhood Club Recreation and Wellness Center, and that there will be times when access to the center, or parts thereof, will not be available to pass holders. 5. I verify that the information given in this application is true and correct. 6. I am obligated for payment of the Membership/Pass(es) and any other outstanding fees related to it. If any outstanding balances are due to the Neighborhood Club, the Membership Pass will be temporarily suspended until the balance due to the Neighborhood Club is paid in full. Signature ___________________________________________ Date ____________________ (If under age 18, must also be signed parent/guardian For Office Use Only: Date Received: __________ New Household: Yes NO Proof Provided _____________ Staff Initials_____________ October 2012

Neighborhood Club Membership Application

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