Membership Acknowledgement. By signing the Membership Agreement, I acknowledge the following; I agree to comply with the rules and regulations of, and established by, the AtlantiCare LifeCenter. My membership is for a 3-month term and I will have the opportunity to continue LifeCenter Membership upon completion of this term. I am responsible for all costs incurred by AtlantiCare LifeCenter in collecting or attempting to collect any fees or other amounts due to the LifeCenter from me including collection fees, attorney fees and/or court costs. I agree to turn in all membership cards and pay all balances due in full upon termination of my membership. I will provide the LifeCenter all changes to membership on writing (e.g., change of payment method, change of address, etc.). Any notice to me from the LifeCenter may be sent to my last known address of record that I have provided the LifeCenter.
Membership Acknowledgement. The Applicant shall, on the date of its -------------------------- execution hereof, deliver to ASCC a duly executed acknowledgement substantially in the form attached hereto as Exhibit C.
Membership Acknowledgement. Participation in activities at or organised by Central Coast Council Leisure and Pools (CCCLP) is at your risk. When you are (your child/xxxx is) at a CCCLP facility or involved in an activity not at the CCCLP but organised, approved or endorsed by CCCLP or Central Coast Council, such involvement is at your own risk and you have no claim against CCCLP or Council for any personal injury or loss which arise. I have been supplied, read and understood the conditions of membership and the information provided and completed on this form, including the terms and conditions on the reverse side. Member’s Name Signature SIGN HERE D M M Y Y Date I/we request the Monthly Debit Fees of $ be debited from my/our account on the first business day of each month. First Deduction / / I/we understand that monthly memberships continue indefinitely – refer to cancellation policy and procedure on the reverse of this agreement IMPORTANT On the Due Drawing Date of each account, or in the event the due date for payment falls on a day other than a Banking Business Day, the payment will be debited from your account on the next Banking Business Day. Failure to have sufficient funds in your account may result in your bank charging you a dishonour fee in addition to Council’s dishonour fee. If this a joint account, both signatures are required. x I/we have read and accept the terms and conditions set out in the Direct Debit Request Service Agreement. Signature If under the age of 18 years a parent/guardian must sign below. Parent’s / Guardian’s Name D D M M Y Y Signature Signature Date D D M M Y Y SIGN HERE SIGN HERE Date SIGN HERE Date D D M M Y Y Direct Debit Agreement Request for Direct Debit: Central Coast Council - Leisure and Pools (Toukley Aquatic Centre, Lake Haven Recreation Centre and Wyong Olympic Pool) Note: All information provided to Council is strictly confidential. Simply complete this form and return in person to Central Coast Council Leisure and Pools. Direct Debit Request Service Agreement (DDRSA) 1 By signing the Direct Debit Request, you authorise Central Coast Council Leisure & Pools (User ID 313292) to arrange for funds to be debited from your account in accordance with the agreement.
Membership Acknowledgement. By signing the Membership Agreement, I acknowledge the following; • I agree to comply with the rules and regulations of, and established by, the AtlantiCare LifeCenter. • My membership is for a 3-month term and I will have the opportunity to continue LifeCenter Membership upon completion of this term. • I am responsible for all costs incurred by AtlantiCare LifeCenter in collecting or attempting to collect any fees or other amounts due to the LifeCenter from me including collection fees, attorney fees and/or court costs. • I agree to turn in all membership cards and pay all balances due in full upon termination of my membership. • I will provide the LifeCenter all changes to membership on writing (e.g., change of payment method, change of address, etc.). Any notice to me from the LifeCenter may be sent to my last known address of record that I have provided the LifeCenter. Waiver of Liability I am aware that exercise and the use of this facility may involve certain risks that could result in injury, illnesses or even death. I accept any and all inherent risk associated with the use of this facility and participation in activities and programs. I also accept and assume full responsibility for any loss of personal property or property damage. I agree to indemnify and hold harmless all involved parties including AtlantiCare LifeCenter, AtlantiCare Health System and all affiliates, employees and contracted persons from any and all liability or claims by me, members of my family, estate or heirs. (initial) I agree to have $37.25 deducted for the next 3-months. # Member Name (print) Badge Number Date Member signature Witness (Staff) signature
Membership Acknowledgement. Participation in activities at or organised by the Cumberland City Council Swim Centres (CCCSC) is at your risk. When you are (your child/xxxx is) at the CCCSC or involved in an activity not at the CCCSC but organised, approved or endorsed by Cumberland City Council such involvement is at your own risk and you have no claim against Council for any personal injury or loss which arise. I have been supplied, read and understood the conditions of membership and the information provided and completed on this form, including the Membership Terms and Agreement. Members Name Signature Date
