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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






Dependent Child



Dependent Child



Dependent Child



Birth Date

Issue Date


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 Recreation and Wellness Guidelines: The following policies have been established to provide consistent guidelines to assure safe operation and provide enjoyable recreation to all pass holders and guests while using the Neighborhood Club Recreation and Wellness facility. Each guest is responsible for knowledge of these policies and failure to observe them may be cause for suspension or termination of all usage privileges associated with these facilities. Policies may be changed for the best interests of facility operation. Admittance: To access the facilities, all users must purchase a pass (daily, monthly or annual). A membership key fob must be presented by user (except daily users) at the designated point of entry to the facility. Management reserves the right to see the pass at any time during the visit. Lost membership key fobs must be reported as soon as possible and cost $5 to replace. All memberships are non-transferable, except for the Corporate Pass. Anyone who is the owner or recipient of a transferred card will lose facility use privileges. There will be no refunds on membership pass fees. Membership pass holders utilizing the EFT payment method must submit a cancellation form at least 30 days in advance of the fund transfer date to have the pass cancelled for the upcoming month. Medical/Relocation Pass Freeze: A pass freeze is extended to annual members experiencing health problems or temporary relocation only for a minimum of three months to maximum of six months. There will still be an initial $10 processing fee; and a charge of $10 per month to maintain current annual membership. If a (family) pass is put on a “freeze” they will not be permitted to receive a program discount. st Proper documentation may be required. Freeze to begin on 1 of the month and end on last day of month. Children: Children under age 12 must be accompanied and supervised by an individual at least 16 years of age. Minimum age is 16 for fitness room access. Food/Beverages: With the exception of plastic no-spill water bottles, food or beverages must be consumed in designated eating areas and may not be brought in to any recreation area. Lockers: Daily use lockers are available. Personal padlocks are available for sale at the Administration Desk but must be removed daily at the close of business or the lock will be removed and items will be confiscated. Staff has authority to inspect bags, purses, etc for prohibited items. A Family Locker Room is available for children of the opposite sex parent. Prohibited Items/Actions: Pets (unless if leading the blind or by special permission), musical devices with speakers, use of open flames, under the influence of or possession of alcohol, drugs, smoking and tobacco products, glass containers of any kind, solicitation of funds, gambling, in-line skates and skateboards, bicycles (must be placed in supplied bike racks at entrance), religious promotion, use of facility for monetary gain (unless rental fee is paid), use of abusive or profane language or other improper conduct, any act which would endanger staff or other patrons, loitering, removal of property from facilities, and posting of flyers, signs, etc… Safety/Emergency Procedures: Patron safety is the most important concern of our staff and patrons are expected to comply with requests to facility rules. Patrons must recognize their own limitations and act in the best interest of their own safety. During any time, real or simulated emergencies may occur and patrons are expected to comply with staff directives and stay clear of any person involved with the emergency. Injuries should be reported to staff. Schedule: Management reserves the right to change the schedule when it is deemed necessary. Programs and special events have priority over “drop-in” use. A quarterly schedule will be posted to indicate times the gymnasium and pool are available for “drop-in” use. Valuables: Patrons are requested to leave their valuables at home. There will be no checking of valuables and the Neighborhood Club is not responsible for lost or stolen items. Lost and Found: Items will be stored at the Neighborhood Club Administration Desk for no more than 30 days before being discarded or donated to charity. Personal care items will be discarded immediately. Items left in locker overnight will be considered “lost and found” property. Fitness Center: Minimum age is 16 for use in the fitness center. Attendants are available to provide instruction on the proper use of the machines. Chalk is not permitted. Proper athletic clothing required. Open toed shoes are prohibited. Weight collars and the use of a spotter are strongly recommended when using free weights. Use of cardiovascular machines is limited to 30 minutes during busy times. Gymnasium: Soft soled, non-marking shoes are required and open toed shoes are prohibited. Hanging from the basketball rims and nets is prohibited. Recreation equipment may be checked out with a membership key fob. Patrons will be billed full replacement costs if recreation equipment is damaged or not returned. Patrons displaying unsportsmanlike conduct (i.e. trash talking, swearing, excessive pushing, throwing punches) will be asked to leave the facility and face possible suspension of privileges. Basketball game policies are posted inside the gym.

Terms of Electronic Transfer Guidelines • • • •

• •

I understand that I am responsible for ensuring that the account provided has sufficient available funds on my automatic payment date to allow for the automatic deduction of payment for my pass and any associated passes. I understand that the amount of the monthly deduction will be determined at the time the Agreement is completed; unless otherwise notified. I understand that I must pay up for my first month at the time of processing my Membership Pass. I understand installments will be taken from my account on a monthly basis based on the day of my initial enrollment.. I understand that I will receive written notice in advance of any change in the date of my automatic deduction, or any change in the amount due. I understand that automatic deductions will continue even if there is a change in the date of the deductions or amount due for my membership, including the renewal of that membership or the addition or removal of family members from my membership. I understand the Neighborhood Club will suspend my Membership Pass if it is unable to collect any payment due and that I am liable for any uncollected payment and for any fees ($25 Service Fee) or penalties imposed by the Neighborhood Club. This agreement will remain in effect until I have notified the Neighborhood Club in writing at least 30 days prior to my monthly installment date of any changes to my account or other funded accounts that would prevent the monthly charge from being processed.

*This is not a complete list of rules and guidelines, please ask a staff member for a complete list.

Neighborhood Club Membership Application