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Butler County Family YMCA

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					               FA                                                                                               Rose E. Schneider Family YMCA
                                                                                                      2001 Ehrman Rd, Cranberry Twp, PA 16046
                                                                                            (724)452-9122 Fax (724)452-8561 www.bcfymca.org

                    The YMCA is committed to serving people of all ages, races, and economic levels. By answering all questions, you will help us
                    meet this goal. The information is confidential and will not be used for any other purposes. PLEASE PRINT LEGIBLY.

                    PAY-PLAN:   Annual (one payment/year)    Monthly (automatic checking, savings, or credit card drafts)
                    MEMBERSHIP TYPE:       Youth       Individual / Adult   Family

                    PRIMARY MEMBER’S INFORMATION – (Complete for all membership types, including Youth)
TYPE:




                    First Name:                                      MI:                      Last Name:
                                                                     Gender:      Male      Marital Status:     Single       Married
                    Date of Birth:        /     /
                                                                                   Female                       Divorced     Widowed
                    Race:         American Indian        Alaskan Native        African American      Asian/ Pacific Islander
                                  Caucasian/White        Hispanic              Other
                    Mailing Address:
UNIT NUMBER:




                    City:                                                                         State:         Zip:
                                                                      E-Mail:
                    Home Phone: (         )      -
                                                                      ___________________________________________________________
                                                                      I wish to be notified through email about events and news
                    Cell Phone:      (    )     -
                                                                      at my YMCA:             YES     NO
                    Work Phone: (         )     -                     Employer:
                    Emergency Contact Information:
                    First Name:                 Last Name:                        Relationship:            Phone number:
                                                                                                           (     )         -


                    ADDITIONAL INFORMATION FOR PRIMARY MEMBER’S SPOUSE –
                    First Name:                                      MI:                      Last Name:
FIRST NAME:




                                                                     Gender:      Male      Marital Status:     Single       Married
                    Date of Birth:        /     /
                                                                                   Female                       Divorced     Widowed
                    Race:         American Indian        Alaskan Native        African American      Asian/ Pacific Islander
                                  Caucasian/White        Hispanic              Other
                                                                     E-Mail:
                    Home Phone: (         )         -
                                                                     I wish to be notified through email about events and news
                    Cell Phone:      (    )         -                at my YMCA:             YES     NO
                    Work Phone: (         )         -                Employer:
                    Emergency Contact Information:
                    First Name:                Last Name:                         Relationship:            Phone number:
                                                                                                           (     )         -


                     ADDITIONAL INFORMATION FOR CHILDREN –
                                                                                                  Birth
                     First Name:                        MI:   Last Name:                                                          M     F
                                                                                                  Date:    /      /
LAST NAME:




                                                                                                  Birth
                     First Name:                        MI:   Last Name:                                                          M     F
                                                                                                  Date:    /      /
                                                                                                  Birth
                     First Name:                        MI:   Last Name:                                                          M     F
                                                                                                  Date:    /      /
                                                                                                  Birth
                     First Name:                        MI:   Last Name:                                                          M     F
                                                                                                  Date:    /      /

               How did you hear about the Rose E. Schneider Family YMCA?
     Radio                                  Newspaper                       Television                 Place of Employment
     Drive By – Live in Area                Member Referral                 YMCA                       Former Member
     Direct Mail                            Friend / Family                 E-mail                     Medical Referral
     Yellow Pages                           Other

The Butler County Family YMCA is a non-profit organization that only thrives through the contributions of our members
and the community. We hope you will help us to achieve our mission and accomplish our vision of building strong kids, strong
families, and strong communities. Please let us know how you can help:
 Contribute your time                                    Monetary Gift
    Volunteer                                                One-time gift of $
    Board Member                                             Monthly EFT or CC draft of $
    Fundraising                                              I do not wish to contribute today, but would like to be contacted
    Other                                                during the Strong Kids Campaign
 Please contact me by   Phone     E-mail                     No, thank you

AUTHORIZATION TO THE YMCA: YMCA Monthly Automatic Withdrawal is a continuous membership payment
plan. I understand this membership will remain in effect and will continue to be drafted until I give a 30-day
written notification of termination to the YMCA. I have given my authority to the above named bank/credit card
company to honor preauthorized EFT/Charge drawn by the YMCA on my account for the membership payments
as indicated above. I understand that my YMCA Monthly Automatic withdrawal will begin on __________ in the
amount of ____________ and will continue as such until 30 days after my written request for termination of the
membership.

When the bank honors the draft by charging my account, such draft shall constitute my receipt for the payment.
Should any preauthorized draft not be honored by said bank when received by them, then it is understood that
the payment will be collected electronically as well as a $25.00 NSF service fee. Monthly Memberships are a
continuous membership plan. I understand that the membership will remain in effect until I initiate its
termination by giving the YMCA a written notice 30 days prior to my next scheduled monthly withdrawal date.
Failure to give 30 day written termination notice will result in that month's fees being non-refundable.

 I choose to utilize the EFT option for monthly payment (direct debit from my  Checking  Savings account)
Bank Name                                                                      Name on Account
Routing/Transit Number                                                         Account Number
Authorized Signature                                                           Date
 I choose to utilize the Credit Card Payment option for my monthly payment (automatic direct charge to credit card)
Credit Card Type  Visa  MasterCard  American Express                        Card Holder Name
Account Number                                                                 Expiration Date
Authorized Signature                                                           Date

This section for YMCA Membership use only
           FEE                AMOUNT                          PAYMENT                                             COMMENTS
 Prorate                  $                     Cash      Check     Swipe      Account
 Development Fee          $                     Cash      Check     Swipe      Account

           ACTION                 DATE            PROCESSED BY                                          COMMENTS
 Application taken:
 Guest passes given:
 Membership entered:
 Membership checked:


File Notes: ____________________________________________________________________________________________________________
______________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________


                                            REQUEST FOR FINANCIAL ASSISTANCE
Today’s Date: ___________________                                              Preferred contact method:             Mail          E-mail
                                                                                    (must include correct mail/email address on first page)

Gross Annual Income: ________________________________ Number of persons in household: __________
(must include income from all sources for all persons in household)

PLEASE ENCLOSE PROOF OF HOUSEHOLD INCOME (if on Public Assistance, include copy of medical card)

Financial assistance is needed because:
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________

Financial assistance is available for Youth, Individual or Family membership or for Programs only. Certain
limitations apply. Financial assistance is requested for:

Membership:  Youth  Individual  Family - or - Program:  Name of Program ___________________

Amount Requested: $__________                     Amount applicant is able to pay: $__________

Please note: To allow adequate processing time for financial assistance for programs, the financial assistance
information form must be received by the YMCA at least two (2) weeks prior to start of registration for the
program session requested or anticipated membership start date

Signature of applicant (parent or guardian if applicant under 18): _____________________________________

FINANCIAL ASSISTANCE (Scholarship) POLICY: It is the policy of the Butler County Family YMCA to provide services for any person
who desires to participate and understands the benefits of the YMCA, regardless of their ability to pay the standard membership or
program fees. Those not able to pay the full fee may be awarded up to 75% assistance based on their demonstrated need.
GUIDELINES AND ELIGIBILITY:
    Assistance will be granted on the basis of demonstrated financial need. The family income guidelines used by the Butler County
     Family YMCA will be used as initial eligibility criteria.
    The YMCA believes a strong sense of ownership and pride is developed if the financial assistance recipient contributes to the cost of
     their YMCA involvement; therefore, applicants will be asked to pay a portion of the membership or program fee.
    Financial assistance will be reviewed for eligibility for each membership or program period. Applicants must re-apply at the expiration
     of each scholarship period, which is typically a period of either six (6) months, one (1) year, or one (1) program cycle.
HOW TO APPLY: Applicants must complete the standard YMCA membership application and the Request for Financial Assistance.
Forms an supporting documentation can be dropped off at the YMCA or mailed to :                Rose E Schneider Family YMCA
                                                                                               Attn: Membership Director
                                                                                               2001 Ehrman Road
                                                                                               Cranberry Twp, PA 16066
SELECTION PROCESS: Financial assistance eligibility will be determined by the Membership Office, based on a review of the
information form OR personal interview with the applicant. Within 2 to 4 weeks, eligibility will be confirmed or denied by mail or e-mail.
The YMCA must reserve the right to refuse assistance to any applicant.

This section for YMCA Membership use only
   Accept        Deny      Date Response Sent ________________               Recommended By: __________________________
Scholarship granted:            25%         50%           75%                Cost (Program or Monthly/Annual Fee): $ ________
Duration:       6 months       1 year       Cycle__       Other              Amount Granted:                           -   $ ________
Comments:___________________________________________                         Amount Paid by Participant:                   $ ________
Initial
____      MEMBERSHIP AGREEMENT:
          o Suspension or termination of YMCA membership privileges may result from a determination by the Executive Director if
            in his/her discretion a violation of the YMCA Member’s Code of Conduct has occurred.
          o Membership cards remain the property of the YMCA and must be surrendered upon demand of the YMCA.
          o Any membership that lapses for 30 days or more will again be assessed the Development Fee.
          o All fees paid for membership including Development Fees are non-refundable.
          o The YMCA also has my permission to photograph or tape myself, spouse and child(ren) while participating in YMCA
            activities

____      MEMBER'S ONGOING RIGHT TO CANCELLATION: After the first thirty days of membership, you may cancel the
          remainder of your membership at any time by giving the YMCA written notice thirty (30) days in advance of your next
          scheduled day of monthly EFT/Charge. Any membership that lapsed for 30 days or more will again be assessed the
          Development Fee. If the draft is not terminated at the requested termination date, it is my responsibility to notify the YMCA as
          soon as possible. I understand the YMCA will not be liable for drafts that occur after the termination date unless reported
          within 60 days of the requested date.

____      WAIVER: I agree that the YMCA shall not be responsible for any personal injuries or losses sustained by me while on any
          YMCA premises, or as a result of any YMCA sponsored activities. I further agree to indemnify and save harmless the
          YMCA from any claims or demands arising out of any such injuries or losses.

____      MEMBER CODE OF CONDUCT: The YMCA is committed to providing a safe and welcoming environment for all
          members and guests. To promote safety and comfort for all, all individuals are asked to act appropriately at all times when in
          our facility or participating in our programs.

          We expect persons using the YMCA to act maturely, to behave responsibly, and to respect the rights and dignity of others.
          Our Member’s Code of Conduct outlines prohibited behavior, but the actions listed below are not an all-inclusive list of
          behaviors considered inappropriate in our facilities or programs:
            o Using or possessing alcohol or illegal chemicals on YMCA property
            o Smoking in the YMCA facility
            o Carrying or concealing a weapon or any device or object that may be used as a weapon
            o Use of cell phones in the YMCA’s shower and locker room areas
            o Use of any video/picture taking equipment, including camera phones, in YMCA’s shower rooms, locker rooms, and
                fitness center area
            o Harassment or intimidation by words, gestures, body language, or any type of menacing behavior
            o Physical contact with another person in an angry, aggressive or threatening way
            o Verbally abusive behavior, including angry or vulgar language, swearing, name-calling, or shouting
            o Sexually explicit conversation or behavior: any sexual contact with another person
            o Inappropriate, immodest, or sexually revealing attire
            o Theft or behavior that results in the destruction or loss of property
            o Loitering within or on the grounds of the YMCA

          In addition, the YMCA reserves the right to deny access or membership to any person who has been accused or convicted of
          any crime involving sexual abuse, is or has been a registered sex offender, has ever been convicted of any offense relating to
          the use, sale, possession, or transportation of narcotics or habit forming and/or dangerous drugs, or is presently or habitually
          under the influence of dangerous drugs or chemicals, narcotics, or intoxicating beverages.

          Members and guests are encouraged to take responsibility for their personal comfort and safety by asking any person whose
          behavior threatens their comfort to refrain from such behavior. Anyone who feels uncomfortable in confronting a person
          directly should report the behavior to a staff member on duty. YMCA staff members are eager to be of assistance. Members
          and guests should not hesitate to notify a staff member if assistance is needed. In order to be able to carry out these policies,
          we ask that members and guests identify themselves to staff when asked.

          I acknowledge the waiver and membership agreement set forth above and being in sympathy with the Mission
          Statement of the Butler County Family YMCA, and hereby apply for membership. (Parent or guardian must sign if
          applicant is under 18 years of age.

          Member Signature                                                                             Date


          Staff Signature                                                                              Date
AUTHORIZATION TO THE YMCA: YMCA Monthly Automatic Withdrawal is a continuous membership payment plan. I understand this
membership will remain in effect and will continue to be drafted until I give a 30-day written notification of termination to the YMCA. I have
given my authority to the above named bank/credit card company to honor preauthorized EFT/Charge drawn by the YMCA on my account
for the membership payments as indicated above. I understand that my YMCA Monthly Automatic withdrawal will begin on __________ in
the amount of ____________ and will continue as such until 30 days after my written request for termination of the membership.
DEVELOPMENT FEE ($__________ ) AND PRORATE ($___________ ) CHARGED/PAID TODAY BY CASH / CHECK / SWIPE / DRAFT
When the bank honors the draft by charging my account, such draft shall constitute my receipt for the payment. Should any preauthorized
draft not be honored by said bank when received by them, then it is understood that the payment will be collected electronically as well as a
$25.00 NSF service fee. Monthly Memberships are a continuous membership plan. I understand that the membership will remain in effect until I
initiate its termination by giving the YMCA a written notice 30 days prior to my next scheduled monthly withdrawal date. Failure to give 30 day
written termination notice will result in that month's fees being non-refundable
MEMBERSHIP AGREEMENT
o Suspension or termination of YMCA membership privileges may result from a determination by the CEO if in his/her discretion a violation
   of the YMCA Member’s Code of Conduct has occurred.
o Membership cards remain the property of the YMCA and must be surrendered upon demand of the YMCA.
o Any membership that lapses for 30 days or more will again be assessed the Development Fee.
o All fees paid for membership including Development Fees are non-refundable.
The YMCA also has my permission to photograph or tape myself, spouse and child(ren) while participating in YMCA activities
MEMBER's ONGOING RIGHT TO CANCELLATION: After the first thirty days of membership, you may cancel the remainder of your
membership at any time by giving the YMCA written notice thirty (30) days in advance of your next scheduled day of monthly EFT/Charge.
Any membership that lapsed for 30 days or more will again be assessed the Joining Fee. If the draft is not terminated at the requested
termination date, it is my responsibility to notify the YMCA as soon as possible. I understand the YMCA will not be liable for drafts that
occur after the termination date unless reported within 60 days of the requested date.
WAIVER: I agree that the YMCA shall not be responsible for any personal injuries or losses sustained by me while on any YMCA premises,
or as a result of any YMCA sponsored activities. I further agree to indemnify and save harmless the YMCA from any claims or demands
arising out of any such injuries or losses. If the draft is not terminated at the requested termination date, it is my responsibility to notify the
YMCA as soon as possible. I understand the YMCA will not be liable for drafts that occur after the termination date unless reported within 60
days of the requested date.
MEMBER CODE OF CONDUCT: The YMCA is committed to providing a safe and welcoming environment for all members and guests.
To promote safety and comfort for all, all individuals are asked to act appropriately at all times when in our facility or participating in our
programs.

We expect persons using the YMCA to act maturely, to behave responsibly, and to respect the rights and dignity of others. Our Member’s
Code of Conduct outlines prohibited behavior, but the actions listed below are not an all-inclusive list of behaviors considered inappropriate
in our facilities or programs:
o Using or possessing alcohol or illegal chemicals on YMCA property
o Smoking in the YMCA facility
o Carrying or concealing a weapon or any device or object that may be used as a weapon
o Use of cell phones in the YMCA’s shower and locker room areas
o Use of any video/picture taking equipment, including camera phones, in YMCA’s shower rooms, locker rooms, and fitness center area
o Harassment or intimidation by words, gestures, body language, or any type of menacing behavior
o Physical contact with another person in an angry, aggressive or threatening way
o Verbally abusive behavior, including angry or vulgar language, swearing, name-calling, or shouting
o Sexually explicit conversation or behavior: any sexual contact with another person
o Inappropriate, immodest, or sexually revealing attire
o Theft or behavior that results in the destruction or loss of property
o Loitering within or on the grounds of the YMCA

In addition, the YMCA reserves the right to deny access or membership to any person who has been accused or convicted of any crime
involving sexual abuse, is or has been a registered sex offender, has ever been convicted of any offense relating to the use, sale, possession,
or transportation of narcotics or habit forming and/or dangerous drugs, or is presently or habitually under the influence of dangerous drugs
or chemicals, narcotics, or intoxicating beverages.

Members and guests are encouraged to take responsibility for their personal comfort and safety by asking any person whose behavior
threatens their comfort to refrain from such behavior. Anyone who feels uncomfortable in confronting a person directly should report the
behavior to a staff member on duty. YMCA staff members are eager to be of assistance. Members and guests should not hesitate to notify a
staff member if assistance is needed. In order to be able to carry out these policies, we ask that members and guests identify themselves to
staff when asked.
I acknowledge the waiver and membership agreement set forth above and being in sympathy with the Mission Statement of the
Butler County Family YMCA, hereby apply for membership. (Parent or guardian must sign if applicant is under 18 years of age.

Member Signature                                                                                      Date


Staff Signature                                                                                       Date

				
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