This form contains FOR OFFICIAL USE ONLY information which must be protected under the Freedom of Information Act (5 U.S.C. 552) and/or the
Privacy Act of 1974 (5 U.S.C. 552a). Unauthorized disclosure or misuse of PERSONAL INFORMATION may result in disciplinary action, criminal
and/or civil penalties. Further distribution is prohibited without the approval of the author unless the recipient has a need to know in the
performance of official duties. If you have received this in error, please notify the sender and delete all copies.
04/06/2020 - 2353
INSTRUCTIONS: See “Program Instructions and Requirementsfor additional information.
Service Member/Spousecomplete all sections and email signed form to the appropriate MCAO org box.
NOTE: Renewal applications must include the facility attendance report and if applicable, a waiver request for non-compliance. Waived COVID-19.
Section 1
Status (Select ALL That Apply): NEW Request RENEWAL Request Waiver Request
Facility (Select One): YMCA Facility Private Fitness Facility
Fitness Facility Name: ______________________________________________________________________
Street Address: ___________________________________________________________________________
(Category 1 must list their “unit-designated” fitness facility listed on the MCAO approved “Designation Form”)
Section 2
Service (Select ALL That Apply): National Guard Reserve Army Navy Marine Corps Air Force
Assignment Timeline (mm/yyyy) Start: ______________________________ End: _____________________________
Title 10 Category (Select One Category 1 must complete unit information)
Category 1 Active Duty Independent Duty Personnel
Unit Name: _____________________________________ Unit Phone: _______________________
Unit POC: _______________________________________ POC Email: ________________________
Duty Station Street Address: __________________________________________________________
Category 2 Unaccompanied Spouse/Family of Active Duty
Category 3 Unaccompanied Spouse/Family of Deployed Guard and Reserves
Category 4 Community Based Warrior Transition Unit / Warrior Care Unit
Section 3
Membership Type (Select One): Service Member ONLY Spouse ONLY Family (2+)
Service Member
(Last, First): _________________________________________________________ Rank: _________
Duty Email: __________________________________________ Duty Phone: _______________________________
(List ONLY dependents that will use the facility; use additional sheet if necessary)
Spouse (Last, First): ____________________________ Spouse Email (Optional): _______________________________
Child 1: _____________________________ Age: ______ Child 4: ____________________________ Age: ______
Child 2: _____________________________ Age: ______ Child 5: ____________________________ Age: ______
Child 3: _____________________________ Age: ______ Child 6: ____________________________ Age: ______
Member Certification:
I certify the information provided is accurate and all eligibility criteria for the specified category is met (including
Title 10 requirement). I agree to pay any cost above the DoD-funded rate ($50 single / $70 family) to include any optional services I elect. I
understand that I must comply with the mandatory attendance requirement to be eligible for renewal consideration and that intentionally
providing false information to secure services under a Defense contract is cause for disciplinary action and may be prosecutable.
Service Member/Spouse Signature: ________________________________________ Date: __________________
MCAO Verification (Select One): NEW Approved (or) RENEWAL Request for ASYMCA Determination
Digital Signature/Date: ___________________________________________________________________________
click to sign
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