Membership Invoice and Agreement Form (New Club Members DO

Membership Invoice and Agreement Form
(New Club Members DO NOT Complete this form)
This agreement is made as of the ____ day of ____________, 2016 between
Lakemont Swim Club, Inc., a North Carolina non-profit corporation (hereinafter
referred to as the "Club") and the Member of Record as listed below.
All members shall abide by the Lakemont Club Handbook as set forth at:
www.lakemontpool.com.
The Member of Record agrees to pay the Club's annual dues as set forth below upon the signing of this agreement as
well as the Club's annual dues as the Club's Board of Directors establishes each year which shall be payable and due in
full by May 1st of each subsequent year of membership thereafter. Any failure to pay annual dues shall, at the sole
discretion of the Board of Directors, result in immediate cancellation of the non-paying Member's membership.
The 2016 Invoice: Annual Membership dues are as follows (please check the box that applies):
(Membership Dues can be made in 3 equal installments due: March 25; April 15; May 15th)
FAMILY
two adults with child/children residing in the same household
$615
($585 before 4/15)*
SINGLE PARENT
one adult with child/children residing in the same household
$485
($460 before 4/15)*
COUPLE
two adults residing in the same household (no children residing in the household)
$385
($365 before 4/15)*
SINGLE
one adult (no children residing in the household)
$360
($340 before 4/15)*
SENIOR
singles/couples over 65 years of age
$335
($320 before 4/15)*
LEGACY
members/couples who have paid in full for a minimum of 10 years, no dependents
in the home (Legacy Membership requires Board approval)
$220
($210 before 4/15)*
*The Board of Directors is offering an early payment discount for dues paid in full by April 15, 2016
Please return this agreement with check payable to Lakemont Club, Inc. in the amount of $___________________ to:
Lakemont Swim Club; attn: Membership Chairperson; PO Box 18183; Raleigh, NC 27619 (If paid online, submit signed agreement)
List Member of Record's name as it appears on your Membership Certificate (or your invoice envelope):
Name
address
phone
cell
Email
*e-mail addresses provided here are enrolled to receive the Edge, Lakemont Club’s e-newsletter, from which recipients may unsubscribe
List additional Household Residents included in this Membership and, if under 18, their age as of May 1, 2016:
Member 2:
age:
Member 5:
age:
Member 3:
age:
Member 6:
age:
Member 4:
age:
Member 7:
age:
In the signing of this agreement, the Member of Record agrees to the aforesaid terms in their entirety.
X_________________________________________________________
____ /____ /____
Parental Consent and Emergency Contact Information Form
This Emergency Contact form shall be on file with the Club Manager before unattended visitation privileges are granted
This consent form is to be signed only after agreeing to all of the following: Children under the age of 10 shall not be
permitted on Club property unless accompanied by a person 13 years of age or older. Responsibility of the person
accompanying the child to the Club continues while the child remains on Club property. Child Members 10 years of age and
older may visit the Club unattended at the discretion of the Pool Manager and Staff.
EXPECTATIONS
CONSEQUENCES
I understand the following is expected of all children
I agree to the following consequences
1. to abide by the Lakemont Club Handbook
1st strike verbal warning
2. to follow instructions given by the lifeguards
2nd strike time-out; parents/guardians notified
3. to be respectful of the membership and staff
3rd strike removal from club property
All strikes will be noted in a file and be made available to parents/guardians. In the event the above expectations are
continually violated, I understand the Pool Manager reserves the right to revoke said child's privilege of unattended
visitations for a time set forth by the Pool Manager. The Pool Manager has full Board authorization to act at his/her
discretion. *No child shall be removed from club property without parent/guardian notification.*
EMERGENCY CONTACT INFORMATION
FIRST CHOICE
SECOND CHOICE
Name:
Name:
Phone:
Phone:
(Day)
(Night)
(Mobile)
(Day)
(Night)
(Mobile)
EMERGENCY MEDICAL INFORMATION (please complete as applicable for each child)
CHILD'S NAME
Allergy
Medication
MEDICAL INFORMATION
The Member of Record requests that the below-named child(ren) be allowed to visit the facility unattended and by signature
s/he acknowledge(s) that s/he understand(s) and agree(s) to the aforesaid terms in their entirety:
NAME OF CHILD
AGE
CHILD'S SIGNATURE
X
X
X
X
X
X
CONSENT: I specifically consent that the above-named child(ren) be allowed to visit the facility unattended and agree to the
aforesaid terms in their entirety:
X____________________________________________________________________________
____ /____ /2016