2012 – Online Membership Renewal Form

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

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Type of Membership
It is critical that you complete the information below so that we are able to post your payment accurately and update your membership information.
________________________________________________________________________________
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 #
If you are renewing as Dual, Family, or Household membership, you must complete the information below.
________________________________________________________________________________
Information about the Spouse/Other Adult on the membership.
First/Last Name
Date of Birth (dd/mm/yyyy)
Email
Cell Phone #
Employer
Work Phone #
___________________________________________________________
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)
________________________________________________________________________________
Payment Information:
● I understand that half of the amount owed for dues and fees to LSRC must accompany this application and that the balance must be paid no later than April 30, 2011.
● A late fee of $50 will be assessed to all membership renewals postmarked after April 30, 2011.
● 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 (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, Membership Chair at golsrc@yahoo.com or 221-5127 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.

Lakeside Swimmers

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