Membership Agreement - 3 Month Contract

Please fill out the following form to register for a 3-month 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 Name:    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:  
         
MEMBERSHIP AND PRICING OPTIONS:   
   Short Term:    3-Month Term **
      Resident Individual *  $45
      Non-Resident Individual *  $90
  * All New and Renewed (over thirty (30) days of expiration) Memberships require a $25 Activation Fee. 
** Short-term memberships must be paid in full at time of purchase.

CONTRACT TERMS:

I agree to the Contract Terms and Membership Policies:

Signature: Date:


Customer Service will call you to obtain payment information.