Office Use Only
(Membership Expiration Date)
________/_________/_______
ywca aurora membership application
201 N. River St., Aurora, IL 60506 (630) 896-8588 O (630) 896-9277 F www.ywcaaurora.org
General Information Membership fees are non- refundable
______________________________________________________________________________________________________________________
First Name Middle Initial Last Name Nick Name
Address City State Zip Code
______________________________________________________________________________________________________________________
Home Phone Work Phone Cell Phone E-mail Address
Date of Birth _________/__________/________ Age _____________ Sex ______ M ______F
If ywca aurora membership is for a child, please fill out the information below: ______________________________________
(Membership Expiration Date)
Mother’s Name Address (if different from child) Phone Number
Father’s Name Address (if different from child) Phone Number
___________________________________________________________________________________________
Child’s School Name School Address Grade
___________________________________________________________________________________________
Emergency Contact Address Phone
If ywca aurora membership is for a family, please fill out the information below: ______________________________________
(Membership Expiration Date)
______________________________ _____________ _____________ ____________ ________
Child’s Name Male / Female Date of Birth School Grade
______________________________ _____________ _____________ ____________ ________
Child’s Name Male / Female Date of Birth School Grade
______________________________ _____________ _____________ ____________ ________
Child’s Name Male / Female Date of Birth School Grade
Membership Types
Amount New Renewal Amount Paid
Children $20 ________ ________ ________
Teens (13 – 17) $25 ________ ________ ________
Seniors Citizens (65+) $35 ________ ________ ________
Adult $50 ________ ________ ________
Family $75 ________ ________ ________
Demographics (Optional)
The YWCA Aurora relies heavily on public and private funding in order to bring comprehensive programs at a nominal fee. Part of the granting process is to provide vital statistics
to ensure we are assisting the community as a whole. Please help us ensure the accuracy of our agency’s demographics data by providing the following information: (Please circle)
Ethnicity: African American Asian-Pacific Caucasian Native American Latino Other: ____________________
Educational Level: K 1 2 3 4 5 6 7 8 9 10 11 12 Some College Associate’s Degree Bachelor’s Degree Advanced Degree
Marital Status: Single Married Separated Divorced Widowed Family Size: 1 2 3 4 5 6 Other: ___________
Household Income Level: $15,000 and under $15,001 – 20,000 $20,001 – 30,000 $30,001- 40,000
$40,001- $50,000 $50,001-$60,000 $60,001 and more
Photographs
Occasionally photos are taken and used for promotional and marketing materials for the YWCA Aurora. Participants in any YWCA sponsored or collaborative
programs understand that their photos may be used for promotional and/or marketing use. If you would like to be excluded from being included in promotional
or marketing materials for the YWCA Aurora, please initial below.
__________________
(Initials)
ywca aurora release
Release executed on _____________________________________________, 20_______
Date
By: _____________________________________________________________________
Your Name
Address: ________________________________ City: _____________________ Zip; ___________
On behalf of: __________________________________________ Age: ________________
(Child’s Name or Self)
I hereby acknowledge that I/my child, with my consent, do/does voluntarily apply to participate in the classes, programs, and activities of the YWCA Aurora.
I am aware that certain risks of physical injury, including death, damage, loss, may result from my/my child’s use or intended use of the YWCA Aurora’s facilities and equipment
for participation in classes, programs, and activities offered from time to time by the YWCA Aurora, and I agree on my behalf/my child’s behalf, to accept any and all risk of injury
and/or death.
In consideration for being permitted to participate in the classes, programs and activities of the YWCA Aurora, and the use or intended use of its facilities and equipment, therefore,
I do thereby freely and forever release and hold harmless the YWCA Aurora, its officers, directors, agents and employees for myself/my child, my personal representatives, heirs and
assigns, from any and all claims, demands, damages, rights of action or causes of actions, present or future, whether that same be known, anticipated or unanticipated, resulting from
or arising out of my/my child’s use or intended use of the YWCA Aurora facilities and equipment, or from my/my child’s participation in the YWCA Aurora’s classes, programs, and
activities, which may occur in, on, or about the premises owned, leased or operated by the YWCA Aurora.
I HAVE CAREFULLY READ THIS AGREEMENT AND UNDERSTAND ITS CONTENTS. I AM AWARE THAT THIS IS A RELEASE OF LIABILITY AND A CONTRACT
BETWEEN MYSELF/MYCHILD AND THE YWCA AURORA, AND HAVE SIGNED IT ON MY OWN FREE WILL.
___________________________________________________________ _______________________________________
Signature of Participant/Parent Date
