Primary Member Name: _________________________________
p
Policies Signed
p
Release of Liability Signed Staff Initials: ________
Household Family Member 1: _____________________________
p
Policies Signed
p
Release of Liability Signed Staff Initials: ________
Household Family Member 2: _____________________________
p
Policies Signed
p
Release of Liability Signed Staff Initials: ________
Household Family Member 3: _____________________________
p
Policies Signed
p
Release of Liability Signed Staff Initials: ________
Method of Payment:
p
Cash
p
Check
p
Credit Card
p
Payroll Deduction
p
Southern ID
Total Paid: _______ Date Paid: _______ Date Entry Completed: _______
Staff Initials: _______
Name: ________________________________________________________________________ Date of Birth ___________________
Last First Middle (Maiden) mm/dd/year
Address: _________________________________________________________________________ Telephone: ___________________
Street City Apt. # State Zip
Cell
Home
Work
Email Address: ____________________________________________________________________
Emergency Contact: __________________________________ Relationship: ____________________ Telephone: ___________________
Last First
Membership Category:
Student
Employee
Additional Family Member
Stakeholder
Constituent
Community
Pool
(Check with desk worker if you are not sure)
Membership Type:
Month
Annual
Do you have any household family members that will be added to the membership at this time? (Up to 3) YES NO
Family Member 1: ________________________________________________________ Date of Birth ________________________
Last First Middle (Maiden) mm/dd/year
Email Address: ________________________________________________________________ Telephone: ____________________
Family Member 2: ________________________________________________________ Date of Birth ________________________
Last First Middle (Maiden) mm/dd/year
Email Address: ________________________________________________________________ Telephone: ____________________
Family Member 3: ________________________________________________________ Date of Birth ________________________
Last First Middle (Maiden) mm/dd/year
Email Address: ________________________________________________________________ Telephone: ____________________
Membership Application
For Hulsey Wellness Center Staff Use Only
Memberships are non-refundable and on an annual or monthly basis.
Must be age 18 to be eligible for membership.
