GCYMembership

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PLEASE FILL IN ALL FIELDS BELOW:

Name:

Date: MM/DD/YYYY

Youth Parent/Guardian:

Address:

Town:

Zip:

Phone:

Birth Date:

MM/DD/YYYY

FemaleMale

Business Phone:

Emergency Phone:

Type of Membership (Check one)

Health ClubRecreationalBasic

	I understand that membership and program fees are not refundable or transferable.
	I understand that it is advised I check with my physician before participating in YMCA activities.
	I understand that this an Annual Membership and will expire one (1) year from date of purchase. (Bank Drafts excluded)
	I give permission for photographs taken on YMCA premises to be used in YMCA marketing material. (check one) YesNo