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2
INTERESTS
Aerial
Aerobics
Aquatics
Child Care
Family Rec
Fitness
Gracefully Aged 55+
Sports
Strength Training
Summer Camp
Swim Lessons
Therapy
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TYPE OF
MEMBERSHIP
1
INCOME
List total income for anyone 24 years of age or older.
Utilities $______________
Rent $______________
Other $______________
Provide proof of income
and expenses to qualify.
Acceptable Documentation
Check Stubs
Bank Statement
SNAP Letter
SSI or Disability Letter
Unemployment Letter
Child Support
Tax Return
Adult 1 $______________
Adult 2 $______________
Adult 3 $______________
INCOME
Youth (0-18)
Young Adult (19-23)
Adult (24-62)
Adult Couple (24-62)
Senior (63+)
Senior Couple
Family
Flexible Payment Application
If you have extenuating circumstances to be considered please provide the information below.
TELL US MORE...
MEMBERSHIP TYPE _________________________
DISCOUNT AMOUNT _________________________
MONTHLY RATE _________________________
APPROVED BY _________________________
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Signature ______________________________________________________________________ Date ___________________
In consideration of being permitted to utilize the facility, services, and programs of the Martinsville-Henry County Family YMCA, including
but not limited to the observation or use of the facility or equipment and participation in any affiliated program, I hereby agree to the
following, except for any injury, damage, or loss caused solely by the YMCA's gross negligence. I understand that activities involving the
use of equipment and participation in programs carry inherent risks of serious injury or death. I, for myself, any personal representatives,
assignees, heirs, and next of kin, hereby fully release, waive, discharge, and covenant not to sue the YMCA, its operations centers, their
respective officers, directors, managers, trustees, members, volunteers, employees, agents, or representatives from any and all claims for
injuries, damages, or losses incurred from our presence on the premises or while using or observing the use of equipment. I also agree to
indemnify the "releases" and secure them against legal responsibility for any loss, liability, damage, or cost arising from my or my minor
child's presence on the premises, or while using or observing facilities, equipment, or participating in any program affiliated with the
YMCA. Additionally, I grant the Martinsville-Henry County Family YMCA the irrevocable and unrestricted right to use and publish any
photographs, videos, or other media captured for promotional, advertising, or educational purposes without any compensation to me. I
confirm that I am at least 18 years old and have read and understood the terms of this release before signing below.
LIABILITY, PHOTO & VIDEO RELEASE WAIVER
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METHOD OF PAYMENT
EFT(Bank Account)
Routing # _______________________
Account# ___________________________________
OR
Debit/Credit Card
Card # __________________________________________
Exp ____________________ CVV ____________
Pick a draft date
1st or 15th
Feb. 1, 2024 Infrastructure processing fees will be 3% for card payments and $1 for ACH.
1.11.2024
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5
ADDITIONAL HOUSEHOLD MEMBERS
(Must have same address as Applicant)
First Name
Middle
Last Name
DOB
Email
Phone
Gender
First Name
Middle Last Name
DOB
Phone
Gender
First Name Middle
Last Name
DOB Phone
Gender
4
APPLICANT INFORMATION
Mailing Address
City
State
Zip Code
Emergency Contact
Phone
Apt / Suite
First Name Middle Last Name
DOB
Email
Phone
Gender
Employer
Email
Email