YC Adult Membership

Image of Youth Center logo

Adult Membership Registration

Individual Membership ($40/person):

Member's First & Last Name:*

Option 1
Option 2
Option 3

Date of Birth:*

Option 1
Option 2
Option 3

Member's First & Last Name

Option 1
Option 2
Option 3

Date of Birth:

Option 1
Option 2
Option 3

Contact Number*

Option 1
Option 2
Option 3

Address*

Option 1
Option 2
Option 3

City*

Option 1
Option 2
Option 3

State*

Zip*

Option 1
Option 2
Option 3

Email*

Email Confirmation*

Emergency Contact Name*

Option 1
Option 2
Option 3

Relationship*

Option 1
Option 2
Option 3

Contact number*

Option 1
Option 2
Option 3

Emergency Medical Information & Release

I authorize L.C. Sammons Youth Center Staff to seek Medical Treatment in case of an emergency.

List any medical needs we should be aware of.

I understand and acknowledge the nature and risk of adult activities, and I hereby release and waive all rights to claim suit against Mountain Home Parks and Recreation, L.C. Sammons Youth Center, and any officials, employees, agents , and sponsors of either organization regarding any and all liability for injuries, death or property damages arising from the use of said facilities.

Signature (electronically signing constitutes valid signature)*

Option 1
Option 2
Option 3

Date Field*

Membership is not valid until approved and payment received.

Office Use Only

2023

Receipt #_____________________

Payment Method_____________

Check #_______________________

Date___________________________

2024

Receipt #_____________________

Payment Method_____________

Check #_______________________

Date___________________________