Broadwater Athletic Clubs

Member Services - Add Child

Change Address/Phone Number | Add Spouse | Add Child

* indicates a required field
Member's Name:*		Membership Number:*

Address:*

City:*		Zip Code:*

Email:*

Home Phone:*		Work Phone:*

Child dues rate:

	0-4 years	$5 per month
	5-13 years	$12.00 per month

	14-18 years	$16.00 per month

	18-22 years, in college & living at home	$30.00 per month

	Family Max	$109 per month
	(College student's dues do not apply to family max.)


Name:	Birthdate:

Name:	Birthdate:

Name:	Birthdate:

Name:	Birthdate:

All add-ons are for a minimum of 6 months.

Current Month's prorated dues for child(ren) added to membership
will be billed to your credit card or checking account.

Credit Card: Visa Mastercard Discover American Express

Name on Card:

Card Number:		Exp Date:

OR

Checking account:

Bank:

Routing Number:	(9 numbers on the bottom left of check)

Account Number:

If you pay your dues on an annual, semi-annual or quarterly basis, you will be billed on your credit card or checking account for the remaining due months for your child(ren). Members paying monthly will have the dues added to their monthly bill. If you pay via payroll deduct through your employer, please fill out the form below. If your dues are paid in this manner and this form is not filled out, monthly dues for your child(ren) will be charged to your credit card or the checking account used above.

Employer:

I authorize the Broadwater Athletic Club to increase my payroll deduction for the additional cost of adding my child(ren) to my membership.


Comments:


Print this page for your records. Membership cards will be mailed. Use this form to get access to the Clubs until you receive your membership cards.

					Submitting this form indicates your understanding and agreement with all policies and procedures.