Annual Community Membership Application
July 1, 2005 - June 30, 2006
Please print, fill in the form and bring to the Department of Athletics.  Your photo will be taken for your Member ID.

Please check if this membership is a renewal: ________
Name:
 __________________________________
Date:

________________
Address:
 __________________________________
DOB:
 _________________
City:
 _______________________   State: _____   Zip: ________   Card Number: _______________________
Phone:
 ______________________    
Please check any of the following that apply:
$185    _____ Individual Community Resident             _____UMass Boston Staff                   _____UMass Boston Faculty
$210    _____ Family   ** Includes spouse and all household members under the age of 21                  
$30.00 _____ Youth   **Age 16-20, Proof of age is required
Complimentary Memberships    _______Clergy       _______L.E.T.S. Program         ______Senior Citizens **Age 62 or older
Make checks payable to:     UMass Boston Athletic Department                                       Amt. Enclosed: $_______
                                     (Check or money orders accepted for payment; NO CASH ACCEPTED)
Name                                    Relationship                                 Date of Birth                      Card Number
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
(Children under 16 years of age are not allowed to use the facilities or swim in the pool without adult supervision.)
Emergency Contact: _________________________________           Telephone Number: ____________________

Please Note: Absolutely no refunds. Lost cards may be replaced at a charge of $10.00 per card. For further information, please call the
Athletic Department at (617) 287-7801.

For all questions regarding community memberships click here