YMCA Alpine Club Membership Form

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NCYMCA Alpine Club Membership Application

Print out and complete this form. Mail it with payment (payable to North Country YMCA) to:

Dianne L. Rappa, NCYMCA Executive Director, PO Box 123, Bath, NH 03740-0123

Membership runs January through December.

Dues:

Individual - $15/year

Family/Household - $30/year

Circle one:

Adult

Family

Teen

PLEASE PRINT

First Name: __________________________

Last Name: _____________________________

DOB: _______________________________

Gender:

Street: ____________________________________________________________________

Town:_______________________ State: _____________ Zip: _______________________

Home Phone: ___________________________ Work Phone: __________________________

Email Address: ________________________________________________________________

Family Members (complete only if purchasing a family membership):

First Name

Last Name

DOB

Gender

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

Emergency contact name: ___________________________ Phone: ______________________

Please list any physical conditions, allergies, medications, past or current physical injuries, etc. This information is critical for our leaders.

Are you interested in becoming or helping as a trip leader/coordinator? _____________________

For what activity? ________________________________ Certifications: _________________

We welcome any comments or suggestions. Please use back of form. Thank you.

Do you have our current newsletter ? __________________

Warning: Participation in the North Country YMCA Alpine Club does include inherent risks of a physical fitness program including bruises, sprains, & muscle pulls along with some more serious problems such as heart attacks, heart rhythm abnormalities, & other cardio-respiratory problems, etc. - I/we have read the warning and fully understand & acknowledge that I/we appreciate the risks and accept them as my/our own responsibility.

Signature: ___________________________________ Date: _____________________________

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