Please print out this form and mail to the address on the bottom of the form.
THE FOLLOWING PLUS APPROPRIATE FEES, DUES AND BOND PAYMENT, CONSTITUTES AN AGREEMENT TO BECOME A BONDHOLDER OF THE DUMONT SWIM CLUB AND IS CONTINGENT UPON ACCEPTANCE.
There are (4) classes of Membership indicated as follows:
Bond Holder Rates
1) Family - $500 2) Semi-Family - $465 3) Couple - $445 4) Individual - $265
Special Membership: $100 (For individuals, permanent or temporary, residing in the Bondholder's household, e.g., visitor, sitter) Please include with payment and note.
Bond Cost: $600 (Two year payment plan available)
Application Fee: $50 (Include with payment)
Please fill in the information requested below, noting carefully ALL household residents to be included, birth dates, telephone numbers, medical & emergency people, enabling us to maintain proper permanent & emergency records.
NON-COMPLETION OF BOND PAYMENTS WILL RESULT IN FORFEITURE OF ALL BOND MONEY PREVIOUSLY PAID. ANYONE KNOWINGLY FALSIFYING INFORMATION ON THIS APPLICATION MAY BE REMOVED FROM THE CLUB ROSTER AND FORFEIT CLUB DUES.
Circle One: Family Semi-Family Couple Individual
Name: _________________________________ Home Phone # _________________________
Address: ______________________________________________________________________
Please list below each person who is eligible for swimming privileges per above Classes of Membership, including applicants for Special Membership.
Name Date of Birth Relationship
_______________________________ ____________ _____________________
_______________________________ ____________ _____________________
_______________________________ ____________ _____________________
_______________________________ ____________ _____________________
_______________________________ ____________ _____________________
_______________________________ ____________ _____________________
Husband's Work # ____________________ Wife's Work # _____________________
Emergency Contact Name & Phone # ________________________________________________
Pediatrician, Family Physician or both (with phone #) ____________________________________
______________________________________________________________________________
If referred by a current member, please list their name here _______________________________
If you would like to purchase a Guest Card for $45 apiece please iclude with your payment and indicate how many cards you are paying for here. Number of Guest Cards ________
Please remit proper payment to: Dumont Swim Club, P.O. Box 93, Dumont, NJ 07628
APPLICATION FORM