Please print out this form and mail to the address on the bottom of the form.
The undersigned hereby applies for a Season Pass to the DUMONT SWIM CLUB for the 2008 swim season. Upon acceptance of this application, it is understood and agreed that:
1) The Membership fees and types are as follows:
A) Family - $650 B) Semi-Family - $615 C) Couple - $595 D) Individual - $365
Application Fee: $50 (Include with payment, waived if prior Seasonal Swimmer)
Special Membership: $100 (For other individuals, permanent or temporary, residing in the Member's household, e.g., visitor, sitter) Please include with payment and note.
Guest Cards: $40 prior to Memorial Day weekend; $45 thereafter. (Please include with payment and advise how many cards you are purchasing)
2)The persons included in the Pass shall be only those members of the Applicant's immediate household. Please fill in all information requested below, noting carefully ALL household residents. Please notify us if any changes take place during the season.
Circle One: Family Semi-Family Couple Individual
Name: _________________________________ Home Phone # _________________________
Address: ______________________________________________________________________
Please list below each person who is eligible for swimming privileges per above Classes of Membership, including applicants for Special Membership.
Name Date of Birth Relationship
_______________________________ ____________ _____________________
_______________________________ ____________ _____________________
_______________________________ ____________ _____________________
_______________________________ ____________ _____________________
_______________________________ ____________ _____________________
_______________________________ ____________ _____________________
Husband's Work # ____________________ Wife's Work # _____________________
Emergency Contact Name & Phone # ________________________________________________
Pediatrician, Family Physician or both (with phone #) ____________________________________
______________________________________________________________________________
If referred by a current member, please list their name here _______________________________
3) All persons included in this Pass shall abide by the Rules & Regulations of the Dumont Swim Club. Failure to do so will be reason for revocation of this Pass.
4) The Applicant shall NOT be a Bondholder of the Dumont Swim Club. This Pass is valid through Labor Day 2005.
5) The Applicant certifies that the information contained herein is true and that all persons listed above reside with the Applicant. In the event that the Applicant furnishes any false information on this application, it shall be reason to revoke the Pass.
6) If the Pass is revoked for any reason, the Applicant will be entitled to the amount of the fee refundable as determined by the Board of Trustees.
Applicant's Signature ______________________________________
Please remit proper payment to: Dumont Swim Club, P.O. Box 93, Dumont, NJ 07628
APPLICATION FORM