2602 West Vernon Avenue
Kinston, NC 28504
WOODMEN COMMUNITY CENTER
MEMBERSHIP AGREEMENT
________________________
Date
PRIMARY MEMBER NAME
______________________________________________________________ (_______) ______________________
Last Name (PLEASE PRINT) First M.I. Home Phone
______________________________________________________________ (_______) ______________________
Street Address Apt. # Cell Phone
______________________________________________________________
City State ZIP Code Month_______ Day_______ Year________
Date of birth
______________________________________________________________ Male _____ Female _____
Email Address
______________________________________________________________ ____________________________________
Additional Email Address Emergency Contact (Name, Phone)
______Subscribe to Woodmen Community Center newsletter (please initial)
ADDITIONAL FAMILY MEMBERS INCLUDED UNDER MEMBERSHIP
Last Name
First Name M.I. Sex Date of birth (M/D)
__________________ _________________ ____ M/F ___________ __________________
_________________ ____ M/F ___________ __________________ _________________
____ M/F ___________ __________________ _________________ ____ M/F ___________ __________________ _________________ ____ M/F
___________
Employer/School ________________ ________________ ________________
________________ ________________ Cell Numbers
(___)__________
(___)__________
(___)__________
(___)__________
(___)__________
APPLICATION FEE A one-time, non-refundable $25.00 fee paid by all new members upon application. Payment may be made in cash, check
or approved debit or credit card.
MEMBERSHIP FEES are non-refundable and are payable as follows (select membership choice):
( ) Monthly Bank Draft ( ) Six Month ( ) Annual
MEMBERSHIP TYPE MONTHLY MEMBERSHIP FEES
____ Family $60.00
____ Single $44.00
____ Senior (60 years of age and older) $35.00
____ Senior (couple) $50.00
____ Military 10% Discount
____ Application Fee $25.00
____ Student $35.00
OFFICE ONLY
Enrollment Fee $___________
Payment Type Monthly Draft $ ________
Total Paid $_____________
Cash $ ________
Receipt # _______________
ID Verified _______________
Accepted by ____________________________________
Employee’s Name
ATTACH VOIDED CHECK FOR DRAFT HERE
CC 8366 NC 9/12
Check $ ________
Credit Card $ ________
Dues are paid in full annually or by monthly bank draft. An application fee is a one-time, non-refundable processing fee. I understand the Woodmen Community Center,
which also includes the Lions Water Adventure waterpark, will have no liability or responsibility for any personal injuries, or loss or damage to personal property, sustained by
a member while using the facility. Membership cards must be presented to enter the facility. Any member who allows use of his/her membership card by another individual
will be subject to loss of membership privileges.(____) Initial Here
Payment Options:
___ Full Annual Payment: Memberships paid in full annually are invoiced for renewal approximately 30 days prior to renewal date and are payable on or before the said
renewal date. Full annual payments begin on ___________ and end on _________ (renewal date) in the amount of $_________. If I allow my membership to lapse more
than 30 days beyond my renewal date, my membership will be void and will not be reactivated until all fees are paid and my account is made current. (____) Initial Here
___ Six Month Payment: Memberships paid in two payments are invoiced for renewal approximately 30 days prior to renewal date and are payable on or before the said
renewal date. Six month payments begin on ___________ and end on _________ (renewal date) in the amount of $_________. If I allow my membership to lapse more
than 30 days beyond my renewal date, my membership will be void and will not be reactivated until all fees are paid and my account is made current. (____) Initial Here
___ Bank Draft: I give Woodmen Community Center permission to draft my bank account. I understand that my account will be drafted each month and if my draft is
returned unpaid, I will be responsible for the payment amount and any penalties incurred. Your membership and therefore the draft of your bank account is continuous until
you cancel it. I designate my bank draft to be debited on the 5th or 25th day of each month. (____) Initial Here
___ Credit Card: I give Woodmen Community Center permission to charge my credit card. I understand that my account will be charged each month and if my charge is
denied, I will be responsible for the payment amount and any penalties incurred. Your membership and therefore the charge of your credit card is continuous until you cancel
it. I designate my credit card to be charged on the 1st or 15th day of each month. (____) Initial Here
Cancellation: My designated bank draft will continue monthly unless I submit a completed and signed cancellation form submitted at least 30 days in advance.
(____) Initial Here
The Woodmen Community Center may, at its discretion, adjust the monthly rate applicable to my category of membership. I understand I will receive notice at least 30 days
prior to any such change and may terminate my membership at said time. (____) Initial Here
I understand providing incorrect information on my application or incorrect banking information may result in suspension and/or termination of my membership.
(____) Initial Here
I understand if for any reason my bank refuses to honor a monthly bank draft, my membership may be terminated; membership will be considered for reinstatement with
payment of all accumulated fees. I will be charged a fee of $15 per incident for items returned for reason of insufficient funds, closed accounts, or stopped payments
(____) Initial Here
I have received a copy of the Policies and Procedures of Woodmen Community Center. (____) Initial Here
Membership cards remain the property of Woodmen Community Center and must be surrendered upon demand. (____) Initial Here
RELEASE AND WAIVER OF LIABILITY AND INDEMNITY AGREEMENT
In consideration for being permitted to utilize the facilities, services and programs of the Woodmen Community Center including the Water Park (hereinafter “Woodmen
Community Center”) for any purpose, including but not limited to observation or use of facilities or equipment, participation in any program affiliated with the Woodmen
Community Center, the undersigned, for himself or herself and any personal representatives, heirs, and next of kin, hereby acknowledges, agrees and represents that he or
she has, or immediately upon entering or participating will inspect and carefully consider such premises and facilities or the affiliated program. It is further warranted that such
entry into the Woodmen Community Center for observation or use of any facilities or equipment or participation in such affiliated program constitutes an acknowledgement
that such premises and all facilities and equipment thereon and such affiliated programs have been inspected and carefully considered and that the undersigned finds and
accepts same as being safe, reasonably suited for the purpose of such observation, use or participation.
IN FURTHER CONSIDERATION OF BEING PERMITTED TO ENTER THE WOODMEN COMMUNITY CENTER FOR ANY PURPOSE, INCLUDING BUT NOT LIMITED
TO OBSERVATION OR USE OF FACILITIES OR EQUIPMENT, OR PARTICIPATION IN ANY PROGRAM AFFILIATED WITH THE WOODMEN COMMUNITY CENTER,
THE UNDERSIGNED ON THEIR OWN BEHALF AND ON BEHALF OF THEIR SPOUSE AND, IF UNDERSIGNED IS A PARENT OR GUARDIAN, ON BEHALF OF
THEIR CHILDREN OR WARDS HEREBY AGREES TO THE FOLLOWING:
1. THE UNDERSIGNED HEREBY RELEASES, WAIVES DISCHARGES AND COVENANTS NOT TO SUE THE WOODMEN COMMUNITY CENTER, its directors, officers,
employees, and agents (hereinafter referred to as “releasees”) from all liability to the undersigned, his personal representatives, assigns, heirs, and next of kin for any loss or
damage, and any claim or demands therefore on account of injury to the persons or property or resulting in death of the undersigned, whether caused by the negligence of
the releasees or otherwise while the undersigned is in, upon, or about the premises or any facilities or equipment therein, or participation in any program affiliated with the
Woodmen Community Center.
2. THE UNDERSIGNED HEREBY AGREES TO INDEMNIFY AND SAVE AND HOLD HARMLESS the releasees and each of them for any loss, liability, damage, or cost
they may incur due to the presence of the undersigned in, upon, or about the Woodmen Community Center premises or in any way observing or using any facilities or
equipment of the Woodmen Community Center or participating in any program affiliated with the Woodmen Community Center whether caused by the negligence of the
releasees or otherwise.
3. THE UNDERSIGNED HEREBY ASSUMES FULL RESPONSIBILITY FOR ANY RISK OF BODILY INJURY, DEATH OR PROPERTY DAMAGE due to negligence of
releasees or otherwise while in, about, or upon the premises of the Woodmen Community Center and/or while using the premises or any facilities or equipment thereon or
participation in any program affiliated with the Woodmen Community Center.
THE UNDERSIGNED further expressly agrees that the foregoing RELEASE AND WAIVER AND INDEMNITY AGREEMENT is intended to be as broad and inclusive as
permitted by the laws of the state of North Carolina and that if any portion thereof is held invalid, it is agreed that the balance shall, notwithstanding, continue in full legal
force and effect.
THE UNDERSIGNED HAS READ AND VOLUNTARILY SIGNS THE RELEASE AND WAIVER OF LIABILITY AGREEMENT, and further agrees that no oral
representatives, statements, or inducements apart from the foregoing written agreement have been made.
Primary Member Signature:____________________________________________________________________________________ Date:___________________
(Must be at least 18 years old.)
Parent or Guardian Signature: __________________________________________________________________________________ Date:____________________
(Required where student member is less than 18 years old.)