Annual Membership Application
Applicant is a (check one) Resident___ Non-Resident___
I. Membership
Primary Applicant ____________________________________ Age Birthday____/____/____
Address________________________ 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 If yes, explain ___________________________________________________________
Emergency Contact____________________ Relationship__________ Emergency Phone #_________________
Secondary Applicant Age Birthday ____/____/____
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 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 __________________
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 Witness Signature Date
________________________________________
Signature (*Parent/Guardian if minor) Date
How did you learn about the SportsPlex & Aquatics Center?
___Radio ___TV ___Newspaper
___Relative/friend ___Flyer ___Center Newsletter ___Other:________________
FOR OFFICE USE ONLY: Picture ID Required for Age Verification
TYPE MEMBERSHIP PURCHASED: Check one:
RESIDENT
FAMILY $425.00 SR. CITIZEN $250.00 (55+)
INDIVIDUAL $300.00 SR. CITIZEN (COUPLE) $350.00 (55+)
ADULT ACTIVITY CENTER ONLY $60 (55+)
NON-RESIDENT
FAMILY $553.00 SR. CITIZEN $325.00 (55+)
INDIVIDUAL $390.00 SR. CITIZEN (COUPLE) $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. #________