Williamsport YMCA Membership/Non-Member Application

Circle One: Circle One:

First Name Gender Male Female Mailing Address City Cell Phone Emergency Contact Email Phone Relationship Birth Date

Annual (One Payment/Year) Family Single Parent Family

MI

Semi Annual (Two Payment/Year) Adult College Youth

Quarterly (Four Payments/Year) Circle One:

First Name Gender Male Female Mailing Address City Cell Phone Emergency Contact Birth Date

Monthly (Automatic Bank Draft) Guest/Non-Member Metro Account

MI Last Name Marital Status Single Married PO Box State/Zip Code Email Phone Relationship Home Phone Apt. #

Williamsport Only

PRIMARY MEMBER/NON-MEMBER
Last Name Marital Status Single Married PO Box State/Zip Code Home Phone Apt. #

2ND ADULT

CHILD(REN): Children over the age of 18 must show proof of full-time college status to be on a Family/Single Parent Family account
First Name First Name First Name First Name First Name MI MI MI MI MI Last Name Last Name Last Name Last Name Last Name Gender Male Female Gender Male Female Gender Male Female Gender Male Female Gender Male Female Birth Date Birth Date Birth Date Birth Date Birth Date

PLEASE CIRCLE AREAS OF INTEREST Group Exercise Weight Training Youth Sports Adult Sports Aquatics Teen Programs Child Care Senior Programs Volunteering

HOW DID YOU HEAR ABOUT THE YMCA? Radio Television Bill Board Drive-By/Live in Area Direct Mail E-Mail Yellow Pages Newspaper Magazine Place of Employment Member Former Member Friend/Family Medical Referral Other_________________

WOULD YOU LIKE TO CONTRIBUTE TO THE STRONG KIDS CAMPAIGN? If yes, one time gift of $__________ Monthly EFT or CC draft of $________