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Membership Application Primary Family Member Name: City/State/ZipCode: Home Phone: Work Phone: E-mail Address: Membership Card Holders (list all members including the person completing application): Full Name Birth Date Gender All members, 3 years of age and older will receive an identification card. Prior to purchasing a membership, you must read and sign the Membership Agreement form on the back page. If you have any questions, call the Recreation Center office at 721-5269, or visit us at 920 Boulder Drive. Recreation Center Annual (includes all facilities): _____Annual Child (3 - 12 yrs) Membership Resident: $93 Non-Resident: $130 _____Annual Youth (13 - 18 yrs) Membership Resident: $156 Non-Resident: $218 _____Annual Adult (19 - 59 yrs) Membership Resident: $338 Non-Resident: $473 _____Annual Senior (60 yrs & up) Membership Resident: $187 Non-Resident: $260 _____Annual Household Membership (6 people) Resident: $624 Non-Resident: $873 Each additional family member will be charged an additional $25 annually. Recreation Center 6-Month (includes all facilities): Month Child (3 - 12 yrs) Membership Resident: $67 Non-Resident: $98 Month Youth (13 - 18 yrs) Membership Resident: $109 Non-Resident: $156 Month Adult (19 - 59 yrs) Membership Resident: $234 Non-Resident: $364 Month Senior (60 yrs & up) Membership Resident: $130 Non-Resident: $187 Month Household Membership (6 people) Resident: $416 Non-Resident: $624 Each additional family member will be charged an additional $15 annually. Multi-Pass Memberships (20 Visits): _____Child (3 - 12 yrs) Membership Resident $52.50 Non-resident $67.50 _____Youth (13 - 18 yrs) Membership Resident $75.00 Non-resident $97.50 _____Adult (19 - 59 yrs) Membership Resident $90.00 Non-resident $120 _____Senior (60 yrs & up) Membership Resident $86.25 Non-resident $112.50 Ice Arena: Arena Multi-Pass (Admiss Only) Resident: $65 Non-resident $75 Arena Multi-Pass (Admiss & Skate) Resident: $90 Non-resident $100 Month Single Resident $120 Non-resident $190 Month Household Resident $210 Non-resident $320 Each additional family member will be charged an additional $15 I request consideration of a group membership with I request the Installment Billing Plan and agree to pay either by automatic credit/debit card payments or by ACH (Automated Clearing House) funds transfer from my bank account. I request consideration for a partial scholarship award. Form of Payment (check one) Cash Check or MC/Visa Total Enclosed CITY OF LARAMIE Laramie Community Recreation Center 920 Boulder Drive, Laramie, WY, 82073 (307)721-5269 (main desk) (307)721-5284 (Fax) www.ci.laramie.wy.us Signature: Date: Printed Name: Witness: Date: Agreement updated: December 16, 2010 ---PAGE BREAK--- I understand and acknowledge that use of the facilities, equipment and services provided by the City of Laramie involves certain inherent risks. Inherent risks as defined under Wyo. Stat. § 1-1-122, the Recreation Safety Act, means those dangers or conditions which are characteristic of, intrinsic to, or an integral part of any sport or recreational opportunity. Pursuant to Wyo. Stat. § 1-1-123, any person who takes part in any sport or recreational opportunity assumes the inherent risks in that sport or recreational opportunity, whether those risks are known or unknown, and is legally responsible for any and all damage, injury, or death to himself or other persons or property that results from the inherent risks in that sport or recreational opportunity. By signing this waiver, I am asserting that my participation in any sport or recreational activity is voluntary and that I am assuming the inherent risks associated with such activity. I hereby release, waive, discharge, and covenant not to sue, the City of Laramie, Wyoming, a municipal corporation, nor any of its agents, volunteers, assistants, or employees from any and all claims arising in direct relation to my assumption of risk. This is not to include actions based upon negligence of the provider wherein the damage, injury or death is not the result of an inherent risk of the sport or recreational opportunity pursuant to Wyo. Stat. § 1-1-109 and § 1-39-106. I have read and fully understand this waiver of liability and intend by my signature to be a complete and unconditional release of all liability to the greatest extent allowed by the law. Signature: Date: For Recreation Center Use Only: Received by Date of Receipt: Entered by Date of Entry: CITY OF LARAMIE Laramie Community Recreation Center 920 Boulder Drive, Laramie, WY, 82073 (307)721-5269, fax (307)721-5284, www.ci.laramie.wy.us Membership Agreement By initialing this agreement I acknowledge and agree to the following terms: Memberships (Multi-pass, 6-Month and Annual) are non-refundable and non-transferable and may only be used by the authorized member. 6-Month and Annual Memberships are a contractual commitment, whether paying in full or in installments. By accepting our installment plan, you are obligated to complete payments on the entire (6 month/12 month) contract. It is the policy of the Parks and Recreation Department to consider cancellations, transfers, suspensions and refunds only under uncontrollable extenuating circumstances. Any such request must be submitted in writing to the Recreation Manager and must include supporting documentation. Cancellations and refunds may be subject to a cancellation fee of not less than half of the remainder of the contracted fee. 6-Month and Annual Memberships are based on unlimited access to the facility when the facility is open. Memberships will not be pro-rated for closures due to holidays, maintenance, weather, etc. Memberships and membership cards are valid for six months/one year from the date of purchase depending on the membership purchased. Multi-pass memberships are valid for two years from the date of purchase. Unused multi-pass visits expire after two years. Membership rates may increase at the time of renewal. 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 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, 11 years old and under must have a person 18 years of age or older with them within the facility at all times. Youth, 12 years of age and older may be within the facility unaccompanied by an adult. When using swimming pools, children under 8 years old must have an adult with them in the pool area at all times. Children, 6 years and younger must be directly supervised in the water 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, and Community Recreation 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 will not be responsible for lost or stolen articles. I understand that this agreement is an instrument for payment of the membership purchased and I am obligated to fulfill this agreement completely. In the event that I fail to make the payments as outlined on page 1 of this document, I am responsible for all costs and expenses, including attorney fees and collection fees, incurred by the City of Laramie in collecting the balance due. A $25 fee will be charged for any check returned or ACH, credit or debit payment declined due to non-sufficient funds. 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.