Annual Membership Application
Applicant is a (check one) Resident___ Non-Resident___ I. Membership Primary Applicant ____________________________________ Age Address________________________ Birthday____/____/____ City______________________ State______ Zip___________
Home Phone #______________ Cell Phone #_______________ E-mail _______________________________ Place of Employment______________________________ Work Phone #_____________________________ **Are there any conditions that would aid medical personnel in the event of an emergency? ___Yes ___No Secondary Applicant If yes, explain ___________________________________________________________ Age Birthday ____/____/____ Emergency Contact____________________ Relationship__________ Emergency Phone #_________________ Address______________________________ City______________________ State______ Zip_____________ Home Phone #_________________ Cell Phone #___________ E-mail _______________________________ Place of Employment _______________________________Work Phone #_____________________________ Employment Address ___________________________City______________ State_____ Zip_______________ **Are there any conditions that would aid medical personnel in the event of an emergency? ___Yes ___No If yes, explain ______________________________________________________________ Emergency Contact ______________________Relationship__________ Emergency Phone #_____________
II. Family Membership - Please list members of household (under age 22 or listed on previous year’s tax statement)
1. Child’s Name ___Yes___ No
Age
Birthdate
Grade___Gender
**Are there any conditions that would aid medical personnel in the event of an emergency? If yes, explain ______________________________________________________________ Emergency Contact___________________ Relationship___________ Emergency Phone __________________ 2. Child’s Name _____________________________ Age ____ Birthdate _________ Grade _____ Gender **Are there any conditions that would aid medical personnel in the event of an emergency? ___Yes ___No If yes, explain ___________________________________________________________ Emergency Contact __________________Relationship___________ Emergency Phone #__________________ 3. Child’s Name ____________________________ Age_____ Birthdate Grade____ Gender_______ **Are there any conditions that would aid medical personnel in the event of an emergency? ___Yes ___No If yes, explain __________________________________________________________ Emergency Contact___________________ Relationship___________ Emergency Phone #_________________ 4. Child’s Name Age_____ Birthdate__________ Grade____ Gender _______ **Are there any conditions that would aid medical personnel in the event of an emergency? ___Yes ___ No If yes, explain___________________________________________________________ Emergency Contact___________________ Relationship___________ Emergency Phone #_________________
AUTHORIZATION FOR RELEASE
I, ________________________________________________, do hereby release and forever discharge and indemnify and hold harmless the Opelika Parks and Recreation Department, The City of Opelika, its employees, as well as its insurers and participants against loss from and against any and all claims, demands or actions in law or inequity that may hereafter at any time be made or brought by myself or anyone on behalf of said self for the purpose of enforcing a claim resulting in damage, injury, death or any other adverse result which may arise in connection with any association and /or participation in activities provided by the City of Opelika Parks and Recreation Department. It is agreed that this Release and Hold Harmless Agreement shall extend to and include any and all claims which may arise from any claimed or actual negligence, carelessness, fault, act or omission of either myself or the parties herein released. I acknowledge that the sole purpose of this agreement is to relieve the parties herein from any and all liability or exposure to liability regardless of the nature and regardless of causation. I also give permission for OPR to take photographs and/or videos of me and/or my child during OPR activities for publicity use. OPR accepts NO RESPONSIBILITY for lost or stolen items. I hereby acknowledge that the terms herein are contractual in nature and that I have read and understand this Release Agreement.
Signature: _____________________________________
Date: ___________________
It is the policy of Opelika Parks and Recreation that no person shall, on the basis of race, color, creed, religion, sex, age, national origin or disability be denied employment, be excluded from participation in, be denied the benefits of, or be subjected to discrimination in any program or activity. “Something for everyone” is the motto of the Opelika Parks and Recreation Department and we strive to make our community healthier and more livable as we enhance the physical, cultural and social well being of those we serve……
____________________________________
Signature Date ________________________________________ Signature (*Parent/Guardian if minor) Date
____________________________________________
Witness Signature Date
___Radio ___Relative/friend
How did you learn about the SportsPlex & Aquatics Center? ___TV ___Newspaper ___Flyer ___Center Newsletter ___Other:________________
FOR OFFICE USE ONLY:
Picture ID Required for Age Verification
RESIDENT
TYPE MEMBERSHIP PURCHASED: Check one:
FAMILY INDIVIDUAL $425.00 $300.00 SR. CITIZEN $250.00 (55+)
SR. CITIZEN (COUPLE) $350.00 (55+) ADULT ACTIVITY CENTER ONLY $60 (55+) NON-RESIDENT
FAMILY INDIVIDUAL
$553.00 $390.00
SR. CITIZEN SR. CITIZEN (COUPLE)
$325.00 (55+) $455.00 (55+)
ADULT ACTIVITY CENTER ONLY $75 (55+) TOTAL AMOUNT PAID $__________ (cash/check) RECEIPT #________RENEWAL DATE: September 1, 2010 Employee Signature_________________________________ RECTRAC I.D. #________