Prefix Sample Clauses

Prefix. ❑Mr. ❑Mrs. ❑Ms. ❑Dr. ❑Rabbi Gender: ❑Male ❑Female APPLICANT’S SIGNATURE DATE First Name: MI: Last Name: Street Address: Apt#: KATIE & XXXXX XXXX JEWISH COMMUNITY CENTER 000 Xxxxx Xxxxx | Xxxxxxxx, XX 00000 000-000-0000 | 000-000-0000 (fax) | xxxxxxxxxxx.xxx City: State: Zip Code: Home Phone: Cell Phone: Work: Rev. 6/30/2020 Birth Date (mm/dd/yy): Email Address: Children/Dependants (up to 18yrs. and/or full-time college student to 25yrs) Monthly Membership Rates Please check the desired membership level Throwback Rate Regular Rate Name: DOB: (mm/dd/yy) Name: DOB: (mm/dd/yy) Name: DOB: (mm/dd/yy) Name: DOB: (mm/dd/yy) Additional Information How did you hear about us? ❑ Male ❑ Female Relationship : ❑ Male ❑ Female Relationship : ❑ Male ❑ Female Relationship : ❑ Male ❑ Female Relationship : ❑ Single Adult $59 $82 $95 $75 $49 $69 1 Adult (age 18 – 69) ❑ Adult Couple 2 Adults (18 – 69) ❑ Family Couple w/children up to 18yrs and/or full-time college student up to 25yrs ❑ Single Parent Family Single Adult w/children up to 18 yrs and/or full-time college student up to 25yrs ❑ Senior Single Single Adult over the age of 70 ❑ Senior Couple Couple over the age of 70 $45 $60 $75 $60 $35 $50 ❑Mailing ❑Employer ❑JCC Website ❑Social Media ❑Fair/Expo ❑Web Search ❑Neighborhood HOA ❑Jewish Organization ❑Friend/Relative ❑Other Membership Referral Were you referred here by one of our current JCC Members? ❑Yes ❑ No If YES, Great! Who do we thank & send the referral $50 JCC Bucks to? Referring Member’s Name: and because of their referral, an added bonus, YOU will get to enjoy & spend $25 JCC Bucks too! (Please allow 10-12 days for processing & mailing) Affinity Discount Group Is your employer or homeowner association a member of our Affinity Group? If YES, Great! Tell us where you work and/or neighborhood you live in Contact Name: If not, you can help your employer and/or homeowner association in becoming one of our Affinity Group members by putting us in contact with someone there! Facilities Monthly Maintenance Fees [$2.00 - Single & Single Parent] [$3.00 - Couple & Family] Payment Options Monthly or Annual (5% discount on annual payment) ❑MONTHLY: A draft of $ (Monthly Membership Dues & Facility Maintenance Fee) will be processed on the 1st of each month. ❑ANNUAL: A draft of $ (12 Month Total of Membership Dues & Facility Maintenance Fee) will be processed at time of joining. Complete Below Section for Credit/Debit Card or Automatic Bank Draft Initiation/Joining Fee There is a...

Prefix. ❑Mr. ❑Mrs. ❑Ms. ❑Dr. ❑Rabbi Gender: ❑Male ❑Female I/We understand that I/we will be assessed a service charge of $25.00 in the event any payment to the Xxxxx & Xxxxx Xxxx Jewish Community Center is declined. First Name: MI: Last Name: I/We understand that failure to keep account current could result in credit reporting. Street Address: Apt#: I/We understand if a fitness/aquatic orientation is desired, it must be within the first three months of joining. I/We give permission for my/our image(s) to be used in JCC printed, video and website publications. In consideration of participating in JCC activities and to use the facilities and equipment, I/We accept all risk to my/our health and of any injury or death that may result from such participation. I/We hereby release the JCC, its board of directors, officers, employees and representatives from any and all liability from any and all claims and causes of action for loss or damage to my/our property and for any and all illness or injury to my/our person(s), including death, that may result from or occur during participation in a JCC activity. City: State: Zip Code: Home Phone: Cell Phone: Work: Birth Date (mm/dd/yy): Email Address: Marital Status: ❑Married ❑Single ❑Divorced ❑Widowed ❑Domestic Partner Occupation: Business Name In Case of Emergency, please notify Name: Relationship: I, THE UNDERSIGNED, HAVE READ THIS AGREEMENT AND AGREE TO ABIDE BY ITS RULES AND REGULATIONS. I UNDERSTAND THAT MEMBERSHIP IS ON AN ANNUAL BASIS, NON-TRANSFERRABLE, AND Phone Number: Spouse/Partner (Adult 2) Alt Phone Number: THAT DUES ARE NON-REFUNDABLE.

Prefix. ❑Mr. ❑Mrs. ❑Ms. ❑Dr. ❑Rabbi Gender: ❑Male ❑Female I/We understand that I/we will be assessed a service charge of $25.00 in the event any payment to the Xxxxx & Xxxxx Xxxx Jewish Community Center is declined. Failure to keep account current could result in credit reporting. I/We understand if a fitness/aquatic orientation is desired it must be within the first three months of your membership.