Minor Amendment to Individual Membership Agreement and Release of Liability

Minor Amendment to Individual Membership Agreement and Release of Liability

To be filled out by Legal Guardian of Minor (16 or 17 year old) seeking an Individual Membership.
Minor Individual Applicant Name*

First NameLast Name
Minor Email*
example@example.com
Minor Phone (Mobile)*
Please enter a valid phone number.
Date of Birth*

MonthDayYear
Date
Age
token*
Date

MonthDayYear
Date

Membership Agreement: As the legal guardian of the applying minor individual member, I understand that he/she has applied for a Rochester Athletic Club membership and the minor is at least 16 years old. Upon the application acceptance, I acknowledge that I may be held responsible for the prevailing due rates, plus tax for the minor individual membership, and all other monthly charges for goods and/or services regardless of whether the minor individual member actually uses or is able to use the Rochester Athletic Club’s facilities.

Membership Termination Policies: Should the minor individual member choose to resign, I understand that the resignation must be submitted, in writing, on or before the 20th of the month to be effective at the month’s end.

For example, if the effective resignation month is end of May, the Rochester Athletic Club must receive the written resignation on or before May 20.

If this deadline is not met, I acknowledge that I am responsible for an extra month dues. I further acknowledge the responsibility for the account balance being brought to zero.
Parent/Guardian Initials*
Contract Rules and Regulations: I have read a copy of and understand the applicant’s contract for membership with the Rochester Athletic Club.
Parent/Guardian Initials*
Release of Liability: I acknowledge that the use of the services, activities and facilities of the Rochester Athletic Club carries a risk of serious personal injury or death. As consideration for the minor individual member being permitted to use the facilities and services as well as participate in Rochester Athletic Club activities, I expressly agree to assume all risk of serious injury and death, and to release the Rochester Athletic Club, its officers, directors, employees, associates, agents, successors and assigns (“The Released Parties”) from liability for injuries, damages or other loss caused by the negligence or strict liability of the Released Parties. I do not release them from liability for willful or intentional conduct or punitive damages. I also understand that this Release of Liability applies each and every time the Rochester Athletic Club is used by the minor individual member.
Parent/Guardian Initials*

Responsible Parent/Guardian Contact Information
Parent/Guardian Name*

First NameLast Name
Email*
example@example.com
Contact Phone Number*
Please enter a valid phone number.
Mailing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
I accept full responsibility for payment in allowing the applying minor individual member to charge goods and/or services to this membership account. Default credit limit is $200.00; please specify higher acceptable limit if needed
Credit Limit (USD)*
Range between $0 - $1,000.00
Minor is allowed to charge his/her account.*

YesNo

I have read and initialed this Minor Individual Membership Amendment carefully and understand all of its terms and conditions. I sign it voluntarily without reservations.
Parent/Guardian Signature*

Clear
Date

MonthDayYear
Date
Hour MinutesAM/PM Option
Should be Empty:

Minor Amendment to Individual Membership Agreement and Release of Liability

Responsible Parent/Guardian Contact Information