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Membership / Multi Pass / Locker Rental Application Member/Guardian/Primary Adult (18+) Adult Address ____City/State/ZIP Primary Phone ____Secondary Phone_______ E-Mail Address(es) Passes to be issued: Fob # Name Birthdate M/F Fob # Name Birthdate M/F All members, 3 years of age and older, will receive an identification card. Recreation Center Membership _____Annual Single Member: -17 yrs 18-59 yrs 60 + yrs Disability Adult Couple* (18-59 yrs) Senior Couple* (60 yrs & up) Household* (2 adults/2 children<18) Parent Plus 1 Child* (<18) Additional Child* (<18) Only available for household and parent plus memberships. *All household memberships, parent-plus memberships and couple’s memberships must reside in the same residence. Locker Rental (available to Rec Center members only) Location: Men’s Locker Rm* Women’s Locker Rm* Weight Room* Studio B* Cross Train** Locker # Request 2nd Choice * $10/mo $8/mo Rec Center Multi-Pass (20 visits ) NAME Ice Arena Multi-Pass (20 Visits): NAME NAME Public skate (w/o skates) $90 Public skate skates) $127.5 Drop-In activities $120 Contract Membership _________WyoTech (staff or student) __________Semester I request a group membership discount with (organization) staff verification_____ I would like to donate to the Recreation Scholarship Fund in the amount of Payment Form: In-Full: Pass Renewal: Renew Active Code Check Visa MasterCard Disc Amex_____ I hereby authorize the City of Laramie to debit the account used for this transaction per month for the payment of my Recreation Center pass renewal. The debit will be processed the 1st day of each month and will begin the month following the date membership is purchased If the billing/renewal date falls on a weekend or holiday the debit will occur on the next business day following the normal payment date. Initial Received by Clerk Initial Total Paid CITY OF LARAMIE PARKS & RECREATION P.O. Box C / 920 Boulder Drive Laramie, WY 82073 Phone: (307) 721-5269 Fax: (307) 721-5284 Email: [EMAIL REDACTED] Silver Sneakers Code ---PAGE BREAK--- By purchasing a pass, I acknowledge and agree to the following facility use policies: City of Laramie Usage Waiver • Memberships and Multi-Pass passes are non-refundable and non-transferable and may only be used by the authorized member. • Rates may increase at the time of renewal. If there is a rate change during your initial membership period, the new rates will not take effect until your membership period is fulfilled. • Memberships set up with discounts will be asked to verify eligibility at set up and again on an annual basis. • Multi-Pass, and Annual membership fees are based on access to the facility when the facility is open. Memberships will not be pro-rated for closures due to holidays, maintenance, weather, class cancellations, etc. • All members must check in at the front desk or at the outdoor pool by using their membership cards each time they use the Community Recreation Center or Outdoor Pool. Children under 3 are free and are not required to have a membership card. • Membership cards remain the property of the City of Laramie and must be returned if requested. • Children, under 11 must have a person 18 years of age or older with them within the facility at all times. • Youth, 12 years of age through 16 years may be within the facility unaccompanied by an adult after both sign the Youth Access Agreement. • When using swimming pools, children 8-11 years old must have an adult with them in the pool area at all times. Children under 8 years of age must be directly supervised in the water at all times and children 5 years and under must be within arm’s reach of an adult who is in the water with them at all times. • Members and visitors of all ages must abide by all regulations, policies, and procedures of the City of Laramie, Parks and Recreation Dept., Community Recreation Center, and Ice & Event Center or privileges may be revoked or suspended. Appeal procedures are available and will be provided to members and visitors upon request. • The City of Laramie is not responsible for lost or stolen articles. Locks are available for purchase or rental at the Recreation Center Front Desk. • All members are encouraged to obtain their physician’s advice and permission before entering into any physical activities or programs. Participation in any activity or program is at the member’s own risk. In case of an emergency, the Recreation Center will contact 911 for emergency assistance. • Membership Cancellations must be in writing by the 25th of the month in order to cancel billing at the end of the first full month of membership. Cancellations are not considered for the pro-rated month. Failure to pay your installment billing DOES NOT cancel your account. Locker Rental Agreement: • The rental period will be active during your membership. This locker rental agreement will expire at the same time as your membership, unless an earlier expiration is requested. Charges for locker rental will be added to membership billing. Members who have paid in full may choose to make a lump sum payment for locker rental or may set up billing. • A lock will be issued with rental. Failure to return the lock will result in a $20 replacement charge. Personal locks may not be used. Assigned locks may only be used on assigned lockers. • Items left in lockers with an expired rental agreement/membership will be removed on the first day after the expiration. Removed items will be kept for two weeks. Unclaimed items will be donated to charity at the end of the two-week period. • Recreation Center staff reserve the right to check lockers for health/safety/security issues. • All lockers are the property of the LCRC. A fee will be assessed for locker/lock damage caused by negligence or abuse. • All lockers must be vacated during annual maintenance week. Rental rates will not be pro-rated. SIGN