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Member Information

Name *

First

Last *

Last

Date Of Birth *

Gender

Male

Female

OtherOther

Address *

Town *

Zip *

Primary Phone *

Secondary Phone

Business

Company Name

Email *

Occupation

Add Remove

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

First Name

MI

Last Name

Sex

Date Of Birth

Email if over 13

Add Remove

In Case of Emergency

Name

Phone

Cell

Relation

Religious Affiliation (OPTIONAL):

Jewish

OtherOther

Previous JCC member?

Yes

No

Did you tour the JCC?

Yes

No

How did you hear about the JCC?

Referred by a friend? What is their name?

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

I agree to abide by the rules and regulations of the Mid-Island Y JCC. The MIYJCC reserves the right to suspend or revoke membership privileges of the members whose behavior is deemed inappropriate or detrimental in any way to other members or staff. *

Yes

I hereby grant permission to the Mid-Island Y JCC to take photographs and makerecordings to be used in print or for promotional purposes. I understand and agree that Iam not entitled to receive any compensation for the above. *

Yes

I will carry my membership card with me when visiting the Center, I agree to pay a $5 replacement fee if the card is lost or damaged. *

Yes

Membership rates for programs are only valid if membership dues are paid through program completion. *

Yes

Members assume all risks involved in usage of the above facilities and the MIYJCC nor staff are not liable for any injury or harm that occurs on the premises. *

Yes

MEMBERSHIP DUES ARE NON-REFUNDABLE AND NON-TRANSFERABLE

Signature

Clear

Date

Taken by

Dues

$

Enrollment Fee:

$

Total

$

I am paying in full; I will receive a bill each year prior to my renewal date.

Yes

I agree to be charged in 12 monthly payments of on credit card I provided.

Yes

AmountAmount

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.

Signature

Clear

Date

For Office Use Only

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516.822.3535
[email protected]

Category