JIMMY FLOYD FAMILY CENTER
Corporate Membership Agreement
Wilson Co. School System
NAME: _____________________________________________________________
(LAST) (FIRST) (MI)
ADDRESS: __________________________________________________________
CITY:________________________STATE:__________ZIP:____________
MAIN PHONE#:_________________ WORK PHONE#:________________
DATE OF BIRTH:_________________________ GENDER: __________
EMERGENCY PHONE#_____________________ CONTACT NAME:_____________________
HAVE YOU EVER BEEN A MEMBER? Y/N ____ IF SO DO YOU NEED NEW CARDS? Y/N ____
4/2/2013
MEMBERSHIP TYPE:
Check two (Type and Residency)
Single ________Resident________
(City of Lebanon)
Family________ Non-Resident______
**A family is defined as a husband or wife, child, stepchild or foster child (children 18 yrs and younger) Ages 19-21, living at the same address, must show school/college identification to be included on the membership. **Children 9 years and younger must be accompanied by an adult 18 years or older.
ADDITIONAL MEMBERS UNDER THIS AGREEMENT:
Name Relation D.O.B.
1. _____________________________________________
2. _____________________________________________
3. _____________________________________________
4. _____________________________________________
5. _____________________________________________
6. _____________________________________________
4/2/2013
*PAYMENT SCHEDULE*
q Dues for monthly or quarterly $__________ Start Date ___________
- Circle payment type: CASH/CHECK
· The undersigned fully understand and agree that in participating in one or more of the activities or using the facilities that shall be maintained by the Jimmy Floyd Family Center, there is the possibility of accidental or other physical injury. The undersigned further agrees to assume the risk of such injury and further agrees to hold harmless the Jimmy Floyd Family Center, the City of Lebanon, its agents, representatives, successors in interest, employees and assigns by either the undersigned or third parties as a result of the use by the undersigned of the facilities and instruction as offered by the Jimmy Floyd Family Center.
· Although we welcome suggestions and are interested in any complaints our users may have, we do insist that our users abide by Jimmy Floyd Family Center Rules and behave in a civil manner. Violation of rules and/or abusive and disruptive behavior toward staff or other patrons may necessitate a user being asked to leave. Repeat violations can result in revocation of Jimmy Floyd Family Center privileges.
NOTICE TO THE BUYER: DO NOT SIGN THIS CONTRACT UNTIL YOU HAVE READ IT COMPLETELY. YOU ARE ENTITLED TO A COPY OF THE CONTRACT YOU SIGN.
All members 18 years and older must read the contract in its entirety and sign below.
SIGNATURE:_____________________________________________________________________________DATE:_____________
4/2/2013
4/2/2013