Membership Application
Mid-Island Y Jewish Community Center

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Member Application

Category

Choose one category

Member 1

First
Last

Member 2

First
Last

Children (of member (s) to age 25 with I.D.) First

In Case of Emergency

Religious Affiliation (OPTIONAL):
Previous JCC member?
Did you tour the JCC?

Important Information – Please read carefully and check each box indicating your agreement.

Checkboxes

MEMBERSHIP DUES ARE NON-REFUNDABLE AND NON-TRANSFERABLE

$
$
$
I am paying in full; I will receive a bill each year prior to my renewal date.
I agree to be charged in 12 monthly payments of on credit card I provided.
I understand that the 1st year of membership is for a 12 month period. I give the Mid-Island Y JCC permission to charge my credit card monthly until I cancel my membership in writing with 30 days written notice. Membership will be renewed automatically each year. I understand that the membership fees are subject to change and the JCC, at its discretion, may adjust the monthly rate, and charge my credit card applicable to my membership category.

For Office Use Only

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