SHALOM SWIM

1277 East 14th Street (Entrance at Chestnut Street)

347-927-POOL(7665)
shalomdaycamps.com Date ___/____/2012

General Membership Information

Membership Category

Last Name ____________________ First Name __________________

Family (Up to 3 Children)

Address ____________________________________________________

Married Couple

City, State, Zip Code _________________________________________

Individual Adult

Phone # _______________________ e-mail ______________________

Children (Ages 9 to 17)

DOB ___/____/____

Emergency Contact

Gender ____ M ____ F

Spouses Name: Last Name _______________

First Name ____________ Name: _____________________

DOB ___/___/___ Phone # _______________________

Phone # ____________________

Children (Under the age of 18)

Name ________________ Gender ____ DOB ___/___/___/ Grade ____ Name: _____________________
Name ________________ Gender ____ DOB ___/___/___/ Grade ____ Phone # ____________________
Name ________________ Gender ____ DOB ___/___/___/ Grade ____

Yearly Membership Fees

Monthly Membership
Family (Up to 3 Children)
$100.00

Family (Maximum of 3 children up to the age of 17)

$700.00

Each child over the maximum is an additional

$100.00

Married Couple

$90.00

Married Couple

$600.00

Individual Adult

$70.00

Individual Adult

$400.00

Children

$50.00

Children (Ages 9 to 17)

$300.00

Members Benefits
10% off Swimming Lessons (When Available)
20% off Womens Aerobic, Zumba or Self Defense Classes
20% off Mens Karate or Self Defense Classes
10% off our Summer Camp Program

Come As You Go
$15.00 Adults $10 Children