17150 Waterloo, Grosse Pointe, MI 48230 Phone: 313.885.4600 Fax: 313.885.2418 www.neighborhoodclub.org

Recreation and Wellness Center Membership Application Check one box only:

[ ] Adult [ ] Adult+1

[ ] Senior [ ] Senior +1

Payment Type: [ ] Monthly Automatic Credit Card Payment [ ] Pay in Full $___________ How did you hear about us?: Internet ____________ Program Brochure Primary Applicant:

[ ] Monthly Pass Only

[ ] Family [ ] Summer Special [ ] _________________

Gender: [ ] Male

Member

[ ] Daily Pass Only

circle one:

Drive By

check

credit card

OTHER_____________

[ ] Female

First Name ______________________________

Last Name _________________________________

Address _________________________________ City ___________________________ Zip ________ Home Phone ______________ Cell Phone ________________ Emergency Contact Phone _________________ Birthdate ___________________ Age _______ Email Address __________________________________ Additional Family Members (Complete additional form if more than four dependents living in your household) Name

Relationship

Gender

Spouse/Partner

M

F

Dependent Child

M

F

Dependent Child

M

F

Dependent Child

M

F

Birth Date

Issue Date

Cost

Pass Type

Relationship: Dependents age 22 and younger must be a son/daughter or prove dependency on primary applicant. Spouse and dependent(s) with a different last name must provide marriage or birth certificate.

Pass Holder Agreement: 1. I understand that participation in any available activity and use of the equipment and facilities within the Neighborhood Club is at my sole discretion and judgment and is at my own risk. I will appropriately and safely limit my activities and those of my dependents, to take into account my/our physical condition. 2. I hereby voluntarily release and hold harmless the Neighborhood Club its officers, agents, and employees from all liability for all types of damages, loss, and injuries, including death, whether foreseeable or not, sustained by myself, and my minor child, and other family members while participating, watching, and traveling to or from the facilities. 3. I understand the attached policies and agree to abide to their terms and conditions. 4. I understand that the membership is for general use of the Neighborhood Club Recreation and Wellness Center, and that there will be times when access to the center, or parts thereof, will not be available to pass holders. 5. I verify that the information given in this application is true and correct. 6. I am obligated for payment of the Membership/Pass(es) and any other outstanding fees related to it. Membership will be an ongoing membership via automatic credit card payments; no formal renewal process. If any outstanding balances are due to the Neighborhood Club, the Membership Pass will be temporarily suspended until the balance due to the Neighborhood Club is paid in full.

Signature ___________________________________________

Date ____________________

(If under age 18, must also be signed parent/guardian

For Office Use Only: Date Received: __________

New Household: Yes NO

Proof Provided _____________

Staff Initials_____________ Revised September 2016

Neighborhood Club Recreation and Wellness Guidelines: The following policies have been established to provide consistent guidelines to assure safe operation and provide enjoyable recreation to all pass holders and guests while using the Neighborhood Club Recreation and Wellness facility. Each guest is responsible for knowledge of these policies and failure to observe them may be cause for suspension or termination of all usage privileges associated with these facilities. Policies may be changed for the best interests of facility operation. Admittance: To access the facilities, all users must purchase a pass (daily, monthly or annual). A membership key fob must be presented by user (except daily users) at the designated point of entry to the facility. Management reserves the right to see the pass at any time during the visit. Lost membership key fobs must be reported as soon as possible and cost $5 to replace. All memberships are non-transferable, except for the Corporate Pass. Anyone who is the owner or recipient of a transferred card will lose facility use privileges. There will be no refunds on membership pass fees. Membership pass holders utilizing the EFT payment method must submit a cancellation form at least 30 days in advance of the fund transfer date to have the pass cancelled for the upcoming month. Medical/Relocation Pass Freeze: A pass freeze is extended to annual members experiencing health problems or temporary relocation only for a minimum of three months to maximum of six months. There will still be an initial $10 processing fee; and a charge of $10 per month to maintain current annual membership. If a (family) pass is put on a “freeze” they will not be permitted to receive a program discount. Proper documentation may be required. Freeze to begin and end based on anniversary of billing date. Children: Children under age 12 must be accompanied and supervised by an individual at least 16 years of age. Minimum age is 14 for fitness room access. Food/Beverages: With the exception of plastic no-spill water bottles, food or beverages must be consumed in designated eating areas and may not be brought in to any recreation area. Lockers: Daily use lockers are available. Personal padlocks are available for sale at the Administration Desk but must be removed daily at the close of business or the lock will be removed and items will be confiscated. Staff has authority to inspect bags, purses, etc for prohibited items. A Family Locker Room is available for children of the opposite sex parent. Prohibited Items/Actions: Pets (unless if leading the blind or by special permission), musical devices with speakers, use of open flames, under the influence of or possession of alcohol, drugs, smoking and tobacco products, glass containers of any kind, solicitation of funds, gambling, in-line skates and skateboards, bicycles (must be placed in supplied bike racks at entrance), religious promotion, use of facility for monetary gain (unless rental fee is paid), use of abusive or profane language or other improper conduct, any act which would endanger staff or other patrons, loitering, removal of property from facilities, and posting of flyers, signs, etc… Safety/Emergency Procedures: Patron safety is the most important concern of our staff and patrons are expected to comply with requests to facility rules. Patrons must recognize their own limitations and act in the best interest of their own safety. During any time, real or simulated emergencies may occur and patrons are expected to comply with staff directives and stay clear of any person involved with the emergency. Injuries should be reported to staff. Schedule: Management reserves the right to change the schedule when it is deemed necessary. Programs and special events have priority over “drop-in” use. A schedule will be posted to indicate times the gymnasium and pool are available for “drop-in” use. Valuables: Patrons are requested to leave their valuables at home. There will be no checking of valuables and the Neighborhood Club is not responsible for lost or stolen items. Lost and Found: Items will be stored at the Neighborhood Club Administration Desk for no more than 30 days before being discarded or donated to charity. Personal care items will be discarded immediately. Items left in locker overnight will be considered “lost and found” property. Fitness Center: Minimum age is 14 for use in the fitness center. 14 and 15 year olds wishing to use the Fitness Center must have a signed waiver and schedule an orientation before using the fitness center. Attendants are available to provide instruction on the proper use of the machines. Chalk is not permitted. Proper athletic clothing required. Open toed shoes are prohibited. Weight collars and the use of a spotter are strongly recommended when using free weights. Use of cardiovascular machines is limited to 30 minutes during busy times. Gymnasium: Soft soled, non-marking shoes are required and open toed shoes are prohibited. Hanging from the basketball rims and nets is prohibited. Recreation equipment may be checked out with a membership key fob. Patrons will be billed full replacement costs if recreation equipment is damaged or not returned. Patrons displaying unsportsmanlike conduct (i.e. trash talking, swearing, excessive pushing, throwing punches) will be asked to leave the facility and face possible suspension of privileges. Basketball game policies are posted inside the gym.

Terms of Automatic Credit Card Payment Guidelines    

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I understand that I am responsible for ensuring that the account provided has sufficient available funds on my automatic payment date to allow for the automatic deduction of payment for my pass and any associated passes. I understand that the amount of the monthly deduction will be determined at the time the Agreement is completed; unless otherwise notified. I understand that I must pay up for my first month at the time of processing my Membership Pass. I understand installments will be taken from my account on a monthly basis based on the day of my initial enrollment.. I understand that I will receive written notice in advance of any change in the date of my automatic deduction, or any change in the amount due. I understand that automatic deductions will continue even if there is a change in the date of the deductions or amount due for my membership, including the renewal of that membership or the addition or removal of family members from my membership. I understand the Neighborhood Club will suspend my Membership Pass if it is unable to collect any payment due and that I am liable for any uncollected payment and for any fees ($25 Service Fee) or penalties imposed by the Neighborhood Club. This agreement will remain in effect until I have notified the Neighborhood Club in writing at least 30 days prior to my monthly installment date of any changes to my account or other funded accounts that would prevent the monthly charge from being processed. Membership will be an ongoing membership via automatic credit card payments; no formal renewal process. Revised June 2015

17150 Waterloo, Grosse Pointe, MI 48230 Phone: 313.885.4600 Fax: 313.885.2418 www.neighborhoodclub.org

Membership Automatic Credit Card Payment Agreement First Name on Account_________________________ Last Name_____________________________________ Home Address__________________________________ City_____________________ Zip Code___________ Home Phone___________________ Cell Phone _______________________ Email Address ____________________________________________________ I hereby authorize the Neighborhood Club to initiate and receive payment of monthly membership dues and fees via automatic transfer from my credit card as named below. Name on Credit Card ________________________________________________ Exp Date______________ Visa, MasterCard, or American Express (Only) Account # __________________________________________________ Security Code (3 digits on back of Visa, MasterCard. 4 digits on front of American Express) ____________

Terms of Automatic Credit Card Payment Agreement •

I understand that the amount of the monthly deduction will be $_______________ unless I am notified otherwise.

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I understand that my membership is ongoing via automatic credit card payment; no formal renewal process. I understand that I am responsible for ensuring that the account designated above has sufficient available funds on my automatic payment date to allow for the automatic deduction of payment for my pass and any associated passes. I understand that I must pay up for my first month at the time of processing my Membership Pass. I understand installments will be taken from my account on a monthly basis based on the day of my initial enrollment.. I understand that I will receive written notice in advance of any change in the date of my automatic deduction, or any change in the amount due. I understand that automatic deductions will continue even if there is a change in the date of the deductions or amount due for my membership, including the renewal of that membership or the addition or removal of family members from my membership. I understand the Neighborhood Club will suspend my Membership Pass if it is unable to collect any payment due and that I am liable for any uncollected payment and for any fees ($25 Service Fee) or penalties imposed by the Neighborhood Club. I am obligated for payment of the Membership Pass(es) and any other outstanding fees related to it. If any outstanding balances are due to the Neighborhood Club, the Membership Pass will be temporarily suspended until the balance due to the Neighborhood Club is paid in full. This agreement will remain in effect until I have notified the Neighborhood Club in writing at least 30 days prior to my monthly installment date of any changes to my account or other funded accounts that would prevent the monthly charge from being processed. Michigan law governs electronic fund transactions authorized by this agreement in all respects except as otherwise superseded by federal law.

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Signature____________________________________________ Date_______________________________

_ For Office Use Only: Gateway Order #: m-000 ____________ - ____________ Total Due/Month: _________ Beginning on: _______/_______/_______ Date Received: ___________________

Staff Initials_____________

Enter to Gateway on: _______/________/________ Revised March 2016

Enrollment Fee Guidelines

ent and FeeSenior Guidelines Adult Membership - $50

OR

Adult+1, Senior+1, and Family Membership - $75

PLEASE NOTE: 1. If you cancel your membership and re-enroll at a future date, you will be subject to a new enrollment fee. 2. Annual Family Memberships must be active prior to registration, in order to receive member rate on select programs. Memberships cancelled anytime during discounted programs are subject to 30-day notice requirement for membership as well as fee equivalent to program discount rate. (You will be responsible to pay the balance of non-member fee.) 3. 30- DAY NOTICE IS REQUIRED FOR ANY CHANGES AND/OR CANCELLATION IN MEMBERSHIP.

Fitness Age Guidelines

(Fitness Center, Fitness Studio, SEC, Rowing/Fitness Room, Cycle Studio and Gymnasium)

Age 16 and older No restrictions on use of the Fitness Center, Fitness Studio, Sports Enhancement Center, ent Fee Guidelines Rowing/Fitness Room, Cycle Studio, Gymnasium (during open gym times). Age 14 - 15 Fitness Center, Fitness Studio, Sports Enhancement Center, Rowing/Fitness Room and Cycle Studio: Can use unsupervised after completing a scheduled orientation along with a signed parent consent form (available in the Fitness Center). Gymnasium (during open gym times): Full, unsupervised use. Age 9 - 13 Fitness Center: No access. Fitness Studio, Sports Enhancement Center, Rowing/Fitness Room and Cycle Studio: No access except during youth fitness classes. Gymnasium (during open gym times): Full, unsupervised use. Age 8 and under Fitness Center: No access. Fitness Studio, Sports Enhancement Center, Rowing/Fitness Room and Cycle Studio: No access except during youth fitness classes. Gymnasium (during open gym times): Must have direct supervision in the gym by a parent/supervisor* at all times.

Aquatic Age Guidelines Age 14 and older Full, unsupervised use after completing a scheduled orientation along with a signed parent consent ent Fee Guidelines form (available in the Fitness Center). Age 9 - 13 (During family swim time only) Must pass a swim test to swim without a parent/supervisor* in the building. If test is not passed, parent/supervisor* must be in the pool area. Age 8 and Under (During family swim time) Must have direct supervision in the pool area by a parent/supervisor* at all times. Parent/supervisor* must be in water with child within arm’s reach if they have not passed a swim test.

Locker Room Age Guidelines Age 3 and under A parent/supervisor* with a child of the opposite gender age 3 years and under may use the locker ent Fee Guidelines room of the parent/supervisor’s gender. Age 4 and over A parent/supervisor* with a child of the opposite gender age 4 years and over must use the family locker room. * A parent/supervisor must be at least age 16 or older

Signature____________________________________________Date_______________________ January 2017 2016

17150 Waterloo Grosse Pointe, MI 48230 Phone: 313.885.4600 Fax: 313.885.2418 www.neighborhoodclub.org

Teen Use of Fitness Center Agreement All youngsters age 14 or 15 must attend a mandatory fitness center orientation and provide a completed signed waiver of liability prior to using the fitness center or fitness studio.

Participant Information Full Name:______________________________________ Date of Birth:____________________ Current Age ________ Address:_________________________________________City:__________________________ Zip Code:____________

Emergency Contact Information Full Name:______________________________________ Relationship ________________________________________ Daytime Phone:__________________ Cell Phone:___________________ Email:_________________________________

I hereby state that (child’s name) _____________________________________ is in good health and understands the potential physical risks involved with using strength equipment and cardiovascular equipment. Participant also understands that no horseplay or inappropriate behavior will be tolerated in the fitness center or fitness studio and such behavior may result in suspension from the Neighborhood Club in accordance with the Code of Conduct for the facility. I understand that my child must have a parent or family member 18 or older present during Adult Group Exercises classes. I also understand that my child must have a parent or family member 18 or older present when using the Sports Enhancement Center and Rowing/Fitness Room at all times

Liability Waiver/Indemnification Agreement I have received, read, understand and agree to comply with the Neighborhood Club’s rules and regulations on the use of the fitness center. I hereby fully release and discharge the Neighborhood Club, its officers, agents and employees from any and all claims from injuries, including death, damage or loss, which may arise or which may be alleged to have arisen out of, or in connection with the above use of the fitness center in the Neighborhood Club Recreation and Wellness Center. I further agree to indemnify and hold harmless and defend the Neighborhood Club its officers, agents and employees from any and all claims resulting from injuries, including death, damage or loss, including, but not limited to, the general public, which may arise or may be alleged to have arisen out of, or in connection with the above utilization of the Neighborhood Club Recreation and Wellness Center.

Parent or Guardian Signature: _______________________________________________ DATE______________________

Fitness Center Orientation Information:   

Selectorized free weight and plate-loaded strength equipment Cardiovascular equipment Fitness center rules, guidelines, and general safety information

_______ (Participant Initials) I have been instructed on how to safely use the aforementioned equipment and understand the fitness center rules, guidelines, and general safety information. I understand that I must have a parent or family member 18 or older present during Adult Group Exercises classes. I also understand that I must have a parent or family member 18 or older present when using the Sports Enhancement Center and Rowing/Fitness Room at all times.

Date of Orientation: ________________

Signature of Orientation Leader: ______________________________________

Return this form to Fitness Center Staff Revised January 2016

Youth Facility Access for 14 and 15 Year Olds The Neighborhood Club Recreation and Wellness Center is committed to providing a safe and welcoming environment for all.

Facility Use To ensure the safety of all members, the Neighborhood Club has enacted the following revised facility use guidelines pertaining to 14 and 15 year olds. Fitness Center, Fitness Studio, Sports Enhancement Center and Rowing/Fitness Room: Can use unsupervised after completing a mandatory teen orientation and with a signed Teen Use of Fitness Center

Agreement on file. Gymnasium and Pool: Full, unsupervised use.

Teen Orientation The Teen Orientation is completed by one of our fitness professionals and consists of an overview of our facility policies, how to properly use the equipment and basic safety instructions. Teen Orientation sessions will take place as indicated below. All current members ages 14 and 15 who have not completed their mandatory Teen Orientation must do so before they can use the facility. Sessions take place every half hour during the times specified: Tuesdays/Thursdays 5-6 pm Saturdays

11 am -12 pm

If you are not able to attend during these times, please contact our Wellness Coordinator, Becky Caulfield, to schedule an appointment at your convenience at (313) 885-4600 ext.31

I have received, read, understand and agree to comply with the Neighborhood Club’s Youth Facility Access requirements for 14 and 15 Year Olds. Parent/Guardian (Print Name): _________________________________________________________ Parent/Guardian Signature:_____________________________________________Date___________

June 2016