City of New York
Parks & Recreation
www.nyc.gov/parks
MEMBERSHIP REGISTRATION FORM
New Member _______Renewal _______
NAME
DATE OF BIRTH
ADDRESS
CITY
STATE ZIP CODE
PHONE
(
)
E-MAIL
ADDRESS
IN CASE OF EMERGENCY PLEASE NOTIFY:
NAME
RELATIONSHIP
PHONE
(
)
Available Membership Packages: Please one
Adults (Ages 25-61) Seniors (Ages 62+)
All Recreation Centers $150/Year _____$75/Six Months _____
Only Rec. Centers without Indoor Pools $100 One Year _______
Only Rec. Centers without Indoor Pools $50 Six Months
_______
People with Disabilities
All Recreation Centers $25 One Year ___________
All Recreation Centers $25 One Year ____________
Veterans
All Recreation Centers $25 One Year ____________
Young Adults (Ages 18-24)
All Recreation Centers $25 One Year ____________
Youth (Ages 1-17)
All Recreation Centers FREE WITH ID ___________
Conditions of Membership
Entry:
Membership cards must be valid and must be scanned at the FRONT DESK before entering a recreation center. New cards are issued
when enrolling in a new membership package. A $5.00 fee will be charged to re-issue membership cards.
Programs and Fees:
Session fees may apply to Parks instructor-led sessions. Session schedules and rates are subject to change; when possible, advance notice
of changes will be provided. Unauthorized personal training and other unapproved classes are strictly prohibited. Children under 16 must be
participating in a Parks session or accompanied by an adult.
Facility Maintenance and Upgrades:
Parks attempts to keep its recreation centers open to the public as much as possible, but it may be necessary to close a portion or all of
facilities for repairs and restoration. Staff will make reasonable efforts to allow members access to alternative areas during necessary
upgrades and or maintenance of facilities.
Locker Rooms:
Personal belongings are not permitted beyond the lobby of the facility. Members wishing to bring their belongings beyond the lobby must
store their items in the lockers provided, and must bring a sturdy lock to secure their own locker. Valuables should not be brought to the
center. Locks left overnight will be clipped, and locker contents removed and held for thirty (30) days. Parks is not responsible for lost or
stolen property.
Physical Activity:
Members must be in athletic attire and footwear to exercise or participate in fitness or sports activities. Members must be 16 years or older
to use fitness equipment unsupervised during open hours. If unsure how to operate any fitness equipment, please consult a staff member.
Food and Beverages:
Outside food may not be brought into the recreation center, although water in plastic bottles is permitted. Glass bottles are not permitted at
any time.
Behavior/Drug Policy/Membership Suspension and Termination:
No drugs, alcohol, smoking, gambling, weapons, violence, profanity, or other inappropriate behavior or violations of Parks rules and
regulations is permitted. Members must comply with all posted rules; all City, State, and Federal laws, rules, or regulations; Parks policies;
and staff instructions. Failure to do so may result in temporary removal from the center, suspension or termination of membership.
Management reserves the right to amend the conditions of membership without prior notice.
I hereby acknowledge that I have, or my child has, read and understood these Conditions of Membership.
Member Signature
(Parent or legal guardian signature if member is under 18 years old)
Date:
Print Name
PLEASE NOTE: MEMBERSHIP & PROGRAM FEES ARE NON-REFUNDABLE AND NON-TRANSFERRABLE
Please continue to second page.
Recreation Center Participant Agreement, Agreement to Indemnify, and Risk Acknowledgement
In consideration of the services of the City of New York (“City”) acting by and through the New York City Department of Parks & Recreation
(“Parks”), their agents, officers, participants, consultants, employees, and all persons or entities acting in any capacity on their behalf, I
agree to release & discharge the City, on behalf of myself, my children, my parents, my heirs, assigns, personal representatives and estate
as follows:
1: I acknowledge that participation in recreational activities entails known and unanticipated risks, which could result in physical or
emotional injury, paralysis, death, or damage to myself, to property or to third parties. I understand that such risks cannot be eliminated
without jeopardizing the essential qualities of the activities. In an effort to minimize those risks, I agree to follow all instructions and wear all
the required equipment provided by the staff at the recreation center.
THE RISKS INCLUDE, BUT ARE NOT LIMITED TO:
(1) Nature of the activity.
(2) Latent or apparent defects or conditions in equipment supplied by Parks, or other persons or entity.
(3) Use of property by myself, others or equipment supplied by Parks, or other persons or entity.
(4) Acts of other participants in this activity, employees, or agents of the City or Parks.
(5) My own physical condition, or own acts or omissions.
(6) Conditions of the Parks facility and surrounding grounds or terrain and accidents connected with their use.
(7) First aid emergency treatment or other services.
2: I expressly agree and promise to accept and assume all risks existing in such recreational activities. My participation in these activities is
purely voluntary and I elect to participate in spite of the risks.
3: I hereby voluntarily release, forever discharge, and agree to indemnify and hold harmless the City from any and all claims, demands or
causes of action which are in any way connected with my participation in these activities, on my use of the City’s equipment or facilities,
including any such claims which allege negligent acts or omissions of the City, except if such claims, demands, or causes of action arise out
of gross negligence or willful misconduct of the City.
4: I expressly agree that should the City or anyone acting on their behalf be required to incur attorney’s fees and costs to enforce this
agreement, I shall indemnify and hold them harmless of all such fees and costs.
5: I hereby certify that I have adequate insurance to cover any injury or damage I may cause or suffer while participating or else I agree to
bear costs of such injury or damage myself. I further certify that I have no medical or physical conditions, which could interfere with my
safety in recreational activities, or else I am willing to assume and bear the costs of all risks that may be created, directly or indirectly, by
any such condition.
6: Further, I hereby give permission that any audio and/or visual images captured of me during regular activities at the recreation center
through audio, photo, and/or video means will be used solely for the Parks' promotional material, multimedia, and publication purposes
without further permission and any compensation to me.
By signing this document, I acknowledge that if anyone is hurt, or there is property damage during my participation in a recreation center
activity a court of law may find me to have waived my right to maintain a lawsuit against the City on the basis of any claim from which I have
released them herein.
I HAVE HAD SUFFICIENT OPPORTUNITY TO READ THE ENTIRE DOCUMENT. I HAVE READ AND UNDERSTOOD THIS
DOCUMENT AND I AGREE TO BE BOUND BY ITS TERMS.
Participant’s Signature: ____________________________________________________________ Date: ______________________
Print Name: _____________________________________________________________________
PARENT OR GUARDIANS ADDITIONAL INDEMNIFICATION
(Guardians of participants under the age of 18 must complete this section)
In consideration of _____________________________________ (print minor’s name) (“Minor”) being permitted by the CITY to participate
in its activities and use its equipment and facilities, I further agree to indemnify and hold the CITY harmless with such use or participation by
Minor.
By signing this document, I acknowledge that if anyone is hurt, or property is damaged during the Minor’s participation in this activity, a court
of law may find me to have waived my right to maintain a lawsuit against the CITY, on the basis of any claim from which I have released
them herein.
I HAVE HAD SUFFICIENT OPPORTUNITY TO READ THE ENTIRE PARTICIPANT AGREEMENT, AGREEMENT TO INDEMNIFY, &
RISK ACKNOWLEDGEMENT DOCUMENT ON THE FRONT OF THIS SHEET. I HAVE READ AND UNDERSTOOD, AND I AGREE TO
BE BOUND BY ITS TERMS.
Signature of Parent or Guardian: _________________________________________________________ Date: ______________________
Print Name: ______________________________________________________________________
MOISTEN AND SEAL
New York State Voter Registration Form
Register to vote
With this form, you register to vote in elections in
New York State. You can also use this form to:
change the name or address
on your voter registration
become a member of a political party
change your party membership
To register you must:
be a US citizen;
be 18 years old by the end of this year;
not be in prison or on parole
for a felony conviction;
• not claim the right to vote elsewhere.
Send or deliver this form
Fill out the form below and send it to your
county’s address on the back of this form,
or take this form to the office of your County
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Mail or deliver this form at least 25 days before
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Questions?
Call your County Board of Elections
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Find answers or tools on our website
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Day, through the DMV number (driver’s license
number or non-driver ID number), or the last
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number, you may use a valid photo ID, a current
utility bill, bank statement, paycheck, government
check or some other government document that
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copy of one of those types of ID with this form—
be sure to tape the sides of the form closed.
If we are unable to verify your identity before
Election Day, you will be asked for ID when
you vote for the rst time.
Last name
First name
16
Apt. Number
I need to apply for an Absentee ballot.
I would like to be an Election Day worker.
Middle Initial
Sufx
City/Town/Village
Zip code
Zip code
Afdavit: I swear or afrm that
I am a citizen of the United States.
I will have lived in the county, city or village
for at least 30 days before the election.
I meet all requirements to register
to vote in New York State.
This is my signature or mark in the box below.
The above information is true, I understand that
if it is not true, I can be convicted and fined up
to $5,000 and/or jailed for up to four years.
I do not have a New York State driver’s license or a Social Security number.
x x x x x
Last four digits of your Social Security number
Democratic party
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Conservative party
Green party
Working Families party
Independence party
Women’s Equality party
Reform party
Other
Address (not P.O. box)
Your address was
Your previous state or New York State County was
Your name was
New York State County
3
Have you voted before? Yes No
8
14
15
Your name
More information
Items 6 & 7 are optional
The address
where you live
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you receive mail
Skip if same as above
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Voting information
that has changed
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or you have not voted before
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Verifying your identity above.
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Political party enrollment is
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vote in a primary election of
a political party, a voter must
enroll in that political party,
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otherwise.
Optional questions
Qualications
10
What year?
11
12
Address or P.O. box
P.O. Box
City/Town/Village
9
13
Birth date
Y Y Y YD DM M
/ /
4
6
Phone
Sex M F
5
Sign
Date
Are you a citizen of the U.S.? Yes No
If you answer No, you cannot register to vote.
1
If you answer No, you cannot register to vote unless you will be 18 by the end of the year.
Will you be 18 years of age or
older on or before election day?
Yes No
2
New York State DMV number
It is a crime to procure a false registration or to furnish false information to the Board of Elections.
Please print in blue or black ink.
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Rev. 04/2015
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BOARD OF ELECTIONS
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NEW YORK NY 10275-0067
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Board of Elections Borough Ofces
General Ofce
32 Broadway, 7 Fl
New York, NY 10004-1609
Tel: 1.212.487.5300 / 1.212.487.5400
Phone Bank: 1.866.VOTE.NYC
E-mail: electioninfo@boe.nyc.ny.us
Web Page: www.vote.nyc.ny.us
Staten Island
1 Edgewater Plaza, 4 Fl
Staten Island, NY 10305
Tel: 1.718.876.0079
Manhattan
200 Varick Street, 10 Fl
New York, NY 10014
Tel: 1.212.886.2100
Bronx
1780 Grand Concourse, 5 Fl
Bronx, NY 10457
Tel: 1.718.299.9017
Brooklyn
345 Adams Street, 4 Fl
Brooklyn, NY 11201
Tel: 1.718.797.8800
Queens
126-06 Queens Boulevard
Kew Gardens, NY 11415
Tel: 1.718.730.6730
Borough Ofces
Rev. English 4/15
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If you would like to be an organ and tissue donor, you may enroll in
the NYS Department of Health (DOH) Donate Life™ Registry online
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provide you an opportunity to limit your donation.
By signing below,
you certify that you are:
• 18 years of age or older;
• consenting to donate all of your organs and
tissues for transplantation, research, or both;
• authorizing the Board of Elections to provide
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DOH for enrollment in the Registry;
• and authorizing DOH to allow access to this in-
formation to federally regulated organ procure-
ment organizations and NYS-licensed tissue
and eye banks and hospitals upon your death.
(Optional) Register to donate your organs and tissues
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