Applicant Information
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Gender
Female
Male
Other
Household Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Primary Phone Number
*
Please enter a valid phone number.
Email
*
example@example.com
Emergency Contact
*
First Name
Last Name
Emergency Contact
*
Please enter a valid phone number.
There is another adult in my household:
*
Yes
No
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Second Adult Information
Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Gender
Female
Male
Other
Primary Phone Number
*
Please enter a valid phone number.
Email
*
example@example.com
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Dependent Information
Please list all dependents in your household to include on your YMCA membership.
Number of dependents in household
*
First Name
Last Name
Date of Birth
Female
Male
Other
First Name
Last Name
Date
Female
Male
Other
First Name
Last Name
Date
Female
Male
Other
First Name
Last Name
Date
Female
Male
Other
First Name
Last Name
Date
Female
Male
Other
First Name
Last Name
Date
Female
Male
Other
First Name
Last Name
Date
Female
Male
Other
First Name
Last Name
Date
Female
Male
Other
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To qualify, please provide a Federal Tax Form 1040 (for every adult in the household)
If form 1040 is not available:
Please provide an IRS Verification of Nonfiling Letter and Social Security Benefit Statement (if applicable)
1040 Tax Form, Social Security Benefit Statement or Statement of Nonfilling Letter
*
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Choose a file
If you do not have a 1040 or statement of nonfile, please fill out a form in-person at either branch.
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I receive income from the following sources (Select all that apply):
*
My employer
Other adult in my household
Social Security
Disability
Other
Adult 1: Monthly Income
Adult 2: Monthly Income
Social Security Monthly Income
Disability Monthly Income
Other Monthly Income
Description of "Other" Income
Total Annual Household Income
I certify that the above information is true and complete to the best of my knowledge, and that I do not have additional income not represented above.
*
I Agree
I agree, if necessary, to send additional information and documentation to support the above statements.
*
I Agree
I understand that if I falsify any of the above information, I will not be eligible for assistance now and/or in the future
*
Code of Conduct
We are committed to providing a safe and welcoming environment for all members and guests. To promote safety and comfort for all, we ask individuals to act appropriately at all times when they are in our facility or participating in our programs. Our Code of Conduct reflects our core values of caring, honesty, respect, and responsibility.Specifically, members are NOT to engage in the following activity including:Angry or vulgar language including swearing, name-calling, or shouting.Intentional physical contact with another person in an angry, threatening, or sexual manner.Any demonstration of sexual activity.Harassment or intimidation by words or gestures, body language, or any other menacing behavior.Inappropriate attire. YMCA dress code is enforced by Y staff.Theft or behavior that results in the destruction of property.Carrying, or concealing weapons or devices or objects that may be used as weapons.Using or possessing illegal chemicals or alcohol on Y property, Y vehicles, or at Y sponsored programs.Chronic disregard for Y policies.Any other conduct that is inappropriate, threatening, or offensive in nature.Smoking is not permitted in or outside the YMCA. The YMCA and its property is a smoke-free environment.The use of cell phones with cameras and all other camera or video recording devices are PROHIBITED in all bathrooms, locker rooms and changing areas.Members and guests are encouraged to be responsible for their personal comfort and safety by requesting that the offensive behavior be stopped from any person whose behavior is in violation of the Code of Conduct listed above. If a member feels uncomfortable confronting the person directly, they should report it immediately to a Y staff person. Our staff are here to help make the Y the best part of your day.Since it is contrary to the mission of the YMCA to be a sex offender, the YMCA will deny or revoke a membership to registered sex offenders. The YMCA will suspend membership and activity privileges of any person accused of sexual abuse of a minor until allegations are cleared.I understand that failure to comply with YMCA rules and policies may result in the termination of my membership, exclusion from YMCA programs, and/or exclusion from areas of the facility. The branch executive directors and CEO will review all reported incidents. The decision to suspend or terminate Y membership privileges will be made at their discretion if a violation of the Code of Conduct has occurred. I have read and understand the La Crosse Area Family YMCA Code of Conduct. I agree to all terms and hereby sign it freely and voluntarily.
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I Agree
Release of Liability
I understand that participation in this activity or program carries a risk of injury to me as a participant. This risk of injury can be significant, with potential for permanent disability or death. I agree to follow all rules of the program or activity, to act within the limits of my ability, to maintain control of myself and all equipment I may use in the activity, and refrain from acting in any manner that may cause or contribute to injury of myself or any other person. I fully understand that such rules and equipment cannot completely eliminate the potential for injury. I acknowledge that the La Crosse Area Family YMCA has made a good faith effort to reduce these risks and to make this program activity reasonably safe for my participation. I knowingly and freely assume all such risks, whether known or unknown, which may be connected with or arise out of the program or activity and accept full responsibility for my participation. If, in the course of my participation in the program or activity, I observe an unusual or significant hazard, I will remove myself from participation and bring such hazards to the attention of the program or activity leader immediately. To the fullest extent permitted by law, I hereby forever indemnify, release and hold harmless the La Crosse Area Family YMCA, its officers, agents, employees, sponsors, and any owners or lessors of premises or property used in this program or activity, from any and all liability, claims, damages, losses and expenses of any kind (including attorney fees), for property damage or personal injury, including disability or death, which may arise in any way out of my participation in programs or activities of the La Crosse Area Family YMCA. I expressly indemnify and hold harmless the La Crosse Area Family YMCA, its officers, agents and employees, from and against all injury, damage or expenses arising out of its own negligent acts or omission, unless such expense, injury or property damage result solely from the gross negligence or willful misconduct of the La Crosse Area Family YMCA and/or its agents, officers or employees. By participating in the YMCA Nationwide Membership Program, I agree to release the National Council of Young Men's Christian Associations of the United States of America, and its independent and autonomous member associations in the United States and Puerto Rico, from claims of negligence for bodily injury or death in connection with the use of YMCA facilities, and from any liability for other claims, including loss of property, to the fullest extent of the law. I have read and understand the La Crosse Area Family YMCA Release of Liability and understand that I am assuming certain risk. I agree to all terms and hereby sign it freely and voluntarily.
*
I Agree
Membership Payment Agreement
For bank drafted membership fees, I authorize the La Crosse Area Family YMCA and the financial institution listed to initiate electronic debit entries to my account to be payable to the order of the La Crosse Area Family YMCA. I agree that your rights in respect to each such debit shall be the same as if it were a check drawn or credit card transaction to the La Crosse Area Family YMCA signed personally by me. The authority is to remain in effect until revoked by me in writing, and until you actually receive such notice I agree that you shall be fully protected in honoring any such check or credit card transaction. I further agree that if any such check or credit card transaction be dishonored, whether with or without cause and whether intentionally or inadvertently, I may be charged a fee of up to $20.00 by the La Crosse Area Family YMCA.If paying monthly using automatic deduction as a convenient way to pay for my membership and, for any reason, I wish to terminate or change the status of my membership, I must give the YMCA a 24hour business day notice of cancellation either in-person, over the phone, or via email to our membership team.If prepaying, I understand that my membership is non-refundable and non-transferable to any other person or YMCA.I understand the La Crosse Area Family YMCA reserves the right to increase membership rates as necessary, with at least a 30-day advance written notice.In the event of dangerous weather conditions or other circumstances outside of our control, I understand the La Crosse Area Family YMCA reserves the right to adjust facility hours or close our facilities completely without reimbursement of membership fees. I have read and understand the La Crosse Area Family YMCA Membership Payment Agreement. I agree to all terms and hereby sign it freely and voluntarily.
*
I Agree
Photo/Talent Release
I hereby irrevocably release, consent and allow the La Crosse Area Family YMCA and its agents to use my photograph/likeness/voice, as it pertains to my participation with the YMCA, in any manner for promotional efforts with out expectation of any reimbursement in connection with its use.I have read and understand the La Crosse Area Family YMCA Photo/Talent Release. I agree to all terms and hereby sign it freely and voluntarily.
I Agree
Text Waiver
By participating, you consent to receive text messages from the La Crosse Area Family YMCA. Message and data rates may apply. Reply back to any text with STOP to cancel. Privacy Policy: https://www.laxymca.org/policies/
I Agree
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