Pocahontas Swim Club Membership Application 2018– 3 Payment Family Plan

Date:
Name:
Address:
City: / State: / Zip:
Home Phone: / Cell:
Email Address:

All membership options include the use of the pool through September 3, 2018. Swim and Dive team participation are not included in the price of your membership. Contact the pool or visit our website for these activities.

The 3-Payment plan requires the credit card authorization form included in this application to be filled out and returned to Poco via Email to , snail mail to PO Box 11553, Fort Wayne, IN 46859, or in person. The card provided will be charged automatically on the 7th day of the month. A $5 administrative fee will be added to the total cost of the membership.

Membership Type:

Family Membership$395 + $25 maintenance fee + $5 Admin fee $141.67 charged monthly for 3 months

I am referring a new member:* / Yes: / No:
New Member Name:

*The new membership must be paid for you to receive referral bonus

I (We) hereby subscribe to the membership in Pocahontas Swim Club, Inc. an Indiana non-for-profit corporation and agree to pay by Credit Card as authorized on the sheet included with this application:

Please indicate the names of the others that will be part of your membership. Please note that all parties on membershipmust reside in same household.

Name: / Age: / Relationship to Member:
Name: / Age: / Relationship to Member:
Name: / Age: / Relationship to Member:
Name: / Age: / Relationship to Member:
Name: / Age: / Relationship to Member:
Emergency Contact Name: / Phone:
Should we be aware of any medical conditions?

Credit Card Authorization

Please complete all fields. You may cancel this authorization at any time by contacting us. This authorization will remain in effect until cancelled.

Credit Card Information
Card Type:
Cardholder Name (as shown on card):
Card Number:
Expiration Date (mm/yy): CVV:
Cardholder Zip Code (from credit card billing address):

I, ______, authorize Pocahontas Swim Club to charge my credit card above for agreed upon purchases. I understand that my information will be saved to file for future transactions on my account.

By submitting this application, I agree to abide by the pool rules set forth by Pocahontas Swim Club and enforced by their staff or board members. I also understand that photos of me or members of my family may be included in promotional materials by Pocahontas Swim Club, both on our website and printable materials.

Signature: ______Date: ______