Fillable Mittleman Junior Rays Registration Payment Authorization

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Mittleman Junior Rays Registration Payment Authorization

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The Mittleman Junior Rays Registration Payment Authorization form is 2 pages long and contains:

  • 3 signatures
  • 4 check-boxes
  • 70 other fields

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File type: PDF

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Junior Rays Registration
Payment Authorization
Responsible Party Name __________________________________________________________ Date: _____________
Address _______________________________________________City _________________ State ______ Zip ________
Home Phone ______________________________________ Cell Phone ______________________________________
Email ______________________________________________________________________________________________
Emergency Contact_________________________________ Emergency Phone _______________________________
If participant is a minor:
Parent Name 1 ______________________________________ Parent Name 2 _________________________________
Participant Name
(First and Last)
Age Member
Y/N
Junior Rays
Cost: $90. Member Cost: $75.
Monthly
Fee
TOTAL
AUTOMATIC CREDIT CARD CHARGE
I authorize Mittleman Jewish Community Center (MJCC)
to charge my credit card account to pay the above amount
on approximately the 1st of each month, commencing
____/01/20__.
This authorization is to remain in eect until I provide
written notication. I understand that I have the right to
cancel this authorization by giving written notice to MJCC
ten business days prior to the 1st of the month in which I
want this authority rescinded.
q Mastercard q VISA q American Express
Credit Card #: __________________________________________
Exp. Date: _____________ CVC #: _____________
Signature: _____________________________________________
Date: ______________________
Monthly Authorizations
AUTOMATIC FUNDS TRANSFER
I authorize Mittleman Jewish Community Center (MJCC) to
transfer funds from my checking account to pay the above
amount on my MJCC account on approximately the 1st of
each month, commencing ____/01/20__. (Please attach check
if new authorization.)
I authorize the nancial institution identied below, to
accept these charges to my account. This authorization
is to remain in eect until the MJCC has received written
notication. I understand that I have the right to cancel this
authorization by giving written notice to MJCC ten business
days prior to the 1st of the month in which I want this
authority rescinded.
Bank/Financial Institution: _______________________________
ABA#: __________________________________________________
Account #: _____________________________________________
Account Name: _________________________________________
Signature: _______________________________ Date: _________
Schnitzer Family Campus
6651 SW Capitol Highway, Portland, OR 97219
P: 503.244.0111 | F
: 503.245.4233 | oregonjcc.org
Mittleman
Jewish Community Center
Please note: If you do not want your child’s photo to appear on MJCC’s Facebook
page or in other marketing materials, please initial here _____.
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Name_______________________________________________________________________________
Address______________________________________________________________________________
City____________________________State_______Zip________Phone_________________________
Email Address: __________________________________Referred by__________________________
Facilities you are interested in: _________________________________________________________
Date of Birth : __________________
ALL GUESTS MUST SIGN BEFORE USING FACILITY.
Use of any recreational facility and participation in any activity involves risk and accidental injury despite
all safety precautions. Having been informed of the activities to be conducted by the Mittleman Jewish
Community Center and/or Portland Jewish Academy I/we, as an individual or parent/guardian of the
participants named herein, assume all risks and hazards incidental to the activities, and release from
responsibility all liability, claims, costs and damages including attorney fees and costs and agree to
indemnify and hold harmless Mittleman Jewish Community Center and Portland Jewish Academy, their
ocers, directors, independent contractors, volunteers, and all employees for any illness, injury or
damage to me or my children, or my family members occurring during the use of any recreational facility
or the participation in any activities conducted by the MJCC.
I understand that if I am presently under a doctor’s care that I have received his/her permission to
exercise or participate in a workout program at the Mittleman Jewish Community Center. By signing this
form, I give the MJCC permission to use a photo of me on web and printed materials.
Initial here if you do wish your photo to be used ____
Initial here if you do not wish your photo to be used____
Signature: ______________________________________________________Date: ________________
INTERNAL USE ONLY:
Form of Identication and ID#:______________________________________________________
Veried By:______________________________ Guest Member # : ________________________
Guest Waiver
Tour given by: _____________________ □ No Tour
Guest Pass/Daily User Fee: _______________________
Please Initial: Received By :_______ Paid: ______ CSI:______ Follow up:______
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Mittleman Junior Rays Registration Payment Authorization

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Completed 26 September 2021

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