2012 – Online Membership Application

Lakeside Swim & Racquet Club
P.O. Box 9614 Richmond, VA 23228
Membership Application – 2012 Season

I hereby apply for membership in the Lakeside Swim & Racquet Club, known hereafter as LSRC, and understand that this application is for the people listed below residing in the same household. I am aware of, and will faithfully uphold and abide by, the purposes, principles, rules, and by-laws of the LSRC, now and as hereafter duly adopted.

I understand that the Board of Directors must approve me, my spouse/other, and/or my dependent children for membership as set forth by the LSRC by-laws. If the LSRC Board of Directors does not accept my application, for any reason, all money collected for this membership will be promptly refunded.

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___________________________________________________________
Information about the Membership Owner
First Name
Last Name
Date of Birth (dd/mm/yyyy)
Email
Address
City, State, Zip
Home Phone
Cell Phone
Employer
Work Phone
Emergency Contact Name
Emergency Contact Phone
___________________________________________________________
Information about the Spouse/Other Adult on the membership.
First/Last Name
Date of Birth (dd/mm/yyyy)
Email
Cell Phone Number
Employer
Work Number
___________________________________________________________
Information about Dependent 1
First/Last Name
Date of Birth (dd/mm/yyyy)
___________________________________________________________
Information about Dependent 2
First/Last Name
Date of Birth (dd/mm/yyyy)
___________________________________________________________
Information about Dependent 3
First/Last Name
Date of Birth (dd/mm/yyyy)
___________________________________________________________
Information about Dependent 4
First/Last Name
Date of Birth (dd/mm/yyyy)
___________________________________________________________
Information about Dependent 5
First/Last Name
Date of Birth (dd/mm/yyyy)
___________________________________________________________
Information about Dependent 6
First/Last Name
Date of Birth (dd/mm/yyyy)
________________________________________________________________________________
Membership Fee
Type of Membership
________________________________________________________________________________
Referred by - Important
Please be sure to list the name of the LSRC member who referred you to our club. This is required for that membership to receive credit for your referral. Your friends thank you!
________________________________________________________________________________
Payment Information: I understand that half of the membership fee must accompany this application and that the remainder of the fee must be paid no later than four weeks from the date the application and first payment is received. Access to the facility will not be granted until full payment has been received. Payments can be made in the form of a check (payable to LSRC) or via credit card (only if paying in full). There will be a $10 service fee applied to all credit card transactions and a $30 charge for all returned checks.
Please contact Kim Barnes at golsrc@yahoo.com regarding any questions or concerns.
You will be directed to the online payment screen when you submit this application. You may pay online, or exit the payment screen and mail your payment to LSRC, P.O. Box 9614, Richmond, VA 23228 Be sure to include the membership name with your payment.

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2012 Employment Application

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