Membership Agreement - 1 Year Contract

Please fill out the following form to register for a 1-year membership at the Brushy Creek Community Center.  Once you click the submit button below, your request will be sent to Customer Service who will contact you within one business day to collect payment information.

MEMBER INFORMATION:         
   Last Name:    First Name:    M.I.:   
   Street Address:    City:    Zip:   
   Home Phone:    Cell Phone:    DOB:   
   Email Address:    Allergies:    Sex:  M F  
   Would you like to receive information from the Community Center via email? Yes No  
EMPLOYER INFORMATION:         
   Employer:    Work Phone:       
 
EMERGENCY INFORMATION:         
   Name:    Phone:    Relation:  
   Name:    Phone:    Relation:  
              
FAMILY MEMBERS:         
   Last Name  First Name Birth Date  Sex  Allergies 
         Male Female   
         Male Female   
        Male Female   
         Male Female   
         Male Female   
         Male Female   
         Male Female   
         Male Female   
       
MEMBERSHIP AND PRICING OPTIONS:   
   Senior:    Annual Quarterly **  Monthly ** 
      Resident Senior Pass     $5  ---  --- 
   Regular:         
      Resident Individual *  $112    $33 ($132) **  $14 ($168) **
      Non-Resident Individual *   $277    $77 ($308) **  $27 ($324) **
      Resident Family *   $336    $88 ($352) **  $32 ($384) **
      Non-Resident Family *   $672  $177 ($708) **  $61 ($732) **
   District         
      Resident District Pass Individual *  $165    $47 ($188) **  $17    ($204) **
      Non-Resident District Pass Individual *  $331    $94 ($376) **  $34    ($408) **
      Resident District Pass Family *   $437  $125 ($500) **  $45    ($540) **
      Non-Resident District Pass Family *   $875  $250 ($1,000) **  $90 ($1,080) **
  * All New and Renewed (over thirty (30) days of expiration) Memberships require a $25 Activation Fee. 
** Only available to members that pay by credit card.

CONTRACT TERMS:

I agree to the Contract Terms and Membership Policies:

Signature: Date:


Customer Service will call you to obtain payment information.