Test Membership Application | Commonpoint Queens

Individual/Family Name*

Membership Type*

New Members* 50 Registration Fee - Includes members who do not renew within 30 days. Memberships are non-refundable and non-transferable.

How did you hear about us?*

Friend
Neighbor
Google
Social Media
Other

Email Address*

Address*

Street Address

Address Line 2

City

State / Province / Region

ZIP / Postal Code

Home/Cell Number*

Alternate Number

In case of emergency, please notify:*

Please list a name and the person's relationship to you.

Emergency Contact's Phone Number:*

Emergency Contact's Alternate Phone Number:*

Member #1's Full Name*

Member #1's Sex*

Member #1's Date of Birth (Month, Date, Year)*

Member #1's Occupation*

Member #1 Business Phone Number:*

Member #2's Full Name*

Member #2's Sex*

Member #2's Date of Birth (Month, Date, Year)*

Member #2's Occupation*

Member #2 Business Phone Number:*

Dependent Children (up to 24 and living in same household)*

Please list your child(ren)'s name(s), sex, and date of birth. If not applicable, please write "N/A"

Please charge my registration to my credit card*

Name on card*

Credit Card #*

Security Code #*

Expiration Date:*

Membership Terms*

I agree

I agree to abide by the rules and regulations of Commonpoint Queens and affirm that all the information given above is accurate. I understand that certain programs at Commonpoint Queens may involve strenuous physical activity, that an applicant is responsible for being physically fit for such participation, and Commonpoint Queens is not responsible for injury or other adverse health consequences arising from such participation. I give unconditional permission to Commonpoint Queens to photograph me and/or my children, and to use the photographs to publicize Commonpoint Queens activities in newsletters, brochures, program guides, advertisements and for similar not-for-profit purposes. Membership at Commonpoint Queens depends upon acceptance and observance of the Rules and Regulations of this institution and may be suspended or terminated at the discretion of the Commonpoint Queens administration.

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