First Name _____________________________________________ Last Name _____________________________________________
Mailing Address ________________________________________
City ________________ State _______ Zip Code __________
Home Telephone Number
_______________________________
In case of Emergency call
_______________________________
Telephone __________________________ Relationship __________________________
Email
Address____________________________________ Date of Birth________________
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Membership Category: Please "X" |
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Family |
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Individual |
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Household Information
First
Name
Last
Name Gender
Birth
Date
Relationship
Membership Agreement
As a member of the Italian American Community Center Inc.
(IACC) I agree to abide by the rules and by-laws of the IACC which were
designed for the benefit of all its members. I understand that
participation in the IACC is a privilege and membership may be revoked with just
cause. I agree to fully and truthfully complete my medical screening forms
that may be required as a condition for participation in a IACC program. A
member agrees that use of all facilities will be at the members exclusive
risk. The member also waivers any claim for damage, loss or theft of
member's property arising out of, or in connection with, the use of any IACC
facility, including the parking lot and roadways. My estate, and I hold
harmless the IACC, its officers, directors, and employees from any damages,
claims, loss, and liability relating to my participation in any IACC program
Signature: ____________________________________________ Date: ___________________
References (please
print)
Name
Telephone Number
Relationship
1.___________________________________________________________________________________________________
IACC
member? _____yes ______no
2.___________________________________________________________________________________________________
IACC member? _____yes ______no
Why do you wish to become a member?
____________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
DUES AND BENEFITS
Membership Category
Annual Dues*
(1) Family
Membership
$165
(2) Individual
Membership
$110
* Any household which
includes a head of household, or their spouse, age 65 and over shall receive a 10% discount on annual dues.
* Any household which
includes a head of household, or their spouse, that receives
government benefits for a
permanent 100% disability shall receive 10% discount
on
annual dues.
* Corporation (up to six
individual memberships) $600.00 annual dues.
Membership Categories
(1) Family Membership:
Includes 2 adults and all dependents under and including the age 23 and 1
dependent adult all living in the same household.
((2) Individual Membership:
Includes 1 adult and 1 dependent adult all living in the same household.
If you have any questions please call the IACC office at
(585) 594-8882
Mail to:
Italian American Community Center
150 Frank DiMino Way
Rochester, NY 14624
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