First Name: / Last Name:
Department: / ID/917#:
Phone: / E-Mail:
GENERAL INFORMATION – Adult Household Member (AHM) / Child Dependent (DEP)
AHM Name (if applicable): / ID#:
DEP Name/s (if applicable): / ID/s#:
MEMBERSHIP OPTIONS – ONE-TIME PAYMENT
Annual / Four-Month / One-Month
UWG Employee / FREE / FREE / FREE
Aramark Employee / $275 / $100 / $30
Adult Household Member / $275 / $100 / $30
Child Dependent (18+ yrs. old) / $150 / $50 / $15
UWG Student Stop-out / N/A / $108 / N/A
^MEMBERSHIP OPTIONS – PAYROLL DEDUCTION
% Infinite / Four-Month / One-Month
# ~Adult Household Member – 10 Month / $27.50 / $25 / N/A
# Adult Household Member – 12 Month / $22.92 / $25 / N/A
# * Adult Household Member – Bi-weekly / $11.46 / $12.50 / N/A
# ~ Child Dependent (18+) – 10 Month / $15 / $12.50 / N/A
# Child Dependent (18+) – 12 Month / $12.50 / $12.50 / N/A
# *Child Dependent (18+) – Bi-weekly / $6.25 / $6.25 / N/A
PAYMENT INFORMATION – Must have signature below for payroll deduction
Amount / Deduction Begins
Cash / N/A
Check #______/ N/A
Payroll Deduction / Amount Per
Pay Period
UWG Signature (Primary):
UREC Employee Name (Print) / New Change
Memberships are non-refundable. Members are expected to abide by all UREC / Campus Center policies and procedures. Failure to do so may result in the termination or suspension of privileges without refund.
Payroll Deduction Notes:^ Payroll deductions are processed in accordance with the University Payroll schedule and maintenance deadlines. Depending on time of registration, your membership dates and deduction dates could be aligned or could be up to one month off.
% Infinite deductions recur indefinitely until the employee stops the deduction through University Recreation. (Must complete a minimum of one year.) To stop this membership, a payroll deduction stop form must be completed.
~ 10 Month UWG Employees who select the infinite membership option via payroll deduction pay for and have access for a calendar year, but only are deducted 10 times for that calendar year’s access.
* Bi-weekly deductions are taken from the first two (2) paychecks on months where bi-weekly employees are issued three (3) paychecks.
# UWG Employees CAN deduct AHM or DEP, but the primary member must sign this form to do so. Also, the length of AHM or DEP memberships CANNOT exceed the length of their Primary Member’s agreement.
Membership Conditions:
Members must abide by all Campus Center policies. Membership may not be cancelled before the end of the membership term. When your membership expires, or you stop an infinite membership (after completing the initial 12 months), you will be required to complete another membership form in order to continue as a member. The schedule for implementing and canceling payroll deductions will follow deadlines established by Human Resources. I understand that because I have that access, I share responsibility for the safety and security of the building, and I agree to the following conditions:
- I will not prop open any outside doors of the Campus Center.
- I will not loan or give my ID to someone else to use.
- If I lose my ID, I will immediately report that loss to Auxiliary Services.
My initials indicate that I have read and agree to the Membership Conditions.
My initials indicate that I am responsible for any misconduct in which my secondary member participates.