Membership Form and Contract – Worland Aquatic Center

WAC Membership Contract

Name *

First

Last

Birthdate

Age

Gender

Male
Female

Billing Address *

Address Line 1

Address Line 2

City

State

Zip Code

Needed for credit card processing.

Phone

Email *

Preferred Method of Contact

Mail
Phone
Email

Employer

Employer Phone

Secondary Responsible Party – Personal Data

Must be dependents living in the same household as Responsible Party.

Name *

First

Last

Birthdate

Age

Gender

Male
Female

Phone

Email *

Employer

Employer Phone

Family / Couple Pass (must be dependents living in the same household as Responsible Party)

Dependent Children are under the age of 19.

Dependent 1 Name

Dependent 1 Date of Birth

Dependent 1 Gender

Male
Female

Do You Want To Add Another Dependent?

Initial *

I have received a copy of the Guidelines and Waiver of Liability, Monthly Automatic Payment Agreement and Member Benefits

Waiver of Liability

INDEMNIFICATION AGREEMENT AND COVENANT NOT TO SUE NOTICE: This is a legally binding agreement. By signing this agreement, you give up your right to bring court action to recover compensation or obtain any other remedy for injuries to yourself or your property or for your death arising out of your use of the Worland Aquatic Center now or anytime in the future. Acknowledgement of risk: I, the undersigned user, hereby acknowledge and agree that the sport of swimming or any other activity associated with the use of the Worland Aquatic Center, located at 2250 Howell Ave. Worland, WY, 82401 poses inherent risks. I have full knowledge of the nature and extent of all of the risks associated with the use of the Worland Aquatic Center.

Date

Signature

Membership Options

NOTICE - Any payment made online will have a 3.5% service charge added to their total.

Membership Type	Annual Fee Paid in Full
Family* Military/Corporate	$552 $504
Ages 3-11 Military/Corporate	$225 $195
Ages 12-59 Military/Corporate	$285 $265
Couple Military/Corporate	$408 $360

Ages 60+ Military/Corporate	$252 $228
60+Couple***  Military/Corporate	$300 $276
60+Family***  Military/Corporate	$396 $372

*Family members; must be dependents living in the same household as Responsible Party. 
**Couple; must be two adults living in the same household. 
***60+Single/Couple; patrons age 60 and up.

-ALL MEMBERSHIPS AND PASSES ARE NON-REFUNDABLE AND NON-TRANSFERABLE.
-IF NOTIFCATION IS NOT RECEIVED THE AQUATIC CENTER WILL CONTINUE YOUR AUTOMATIC WITHDRAWALS AND MEMBERSHIP.

I wish to purchase *

Paid In Full Annual Membership
Quarter Pass
6-Month Pass

Annual Member Benefits: $10 off group swim lessons, 5 free guest passes per year. Other discounts may be available for special events.

A Quarter/6 month pass only entitles you to general use of facility during scheduled hours. It does not have the same benefits or discounts as an annual membership.

End Date for Initial 12 Month Contract

Total

$ 0.00

Square *

Card

Name on Card

Primary Responsible Party – Personal Data

Secondary Responsible Party – Personal Data

Family / Couple Pass (must be dependents living in the same household as Responsible Party)

Waiver of Liability

Membership Options

Customer Copy- Annual Membership Contract

Primary Responsible Party – Personal Data

Secondary Responsible Party – Personal Data

Family / Couple Pass (must be dependents living in the same household as Responsible Party)

Waiver of Liability

Membership Options

Customer Copy- Annual Membership Contract

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