Athens YMCA

First Name: *

Last Name: *

Date: *

Birth Date: *

Email: *

Phone: *

Address: *

City: *

State: *

Zip: *

CHANGE REQUEST

DRAFT INFORMATION OR MEMBERSHIP TYPE (Complete Section A)

UPDATE CONTACT INFORMATION (Complete Section B)

GIVING BACK (Complete Section C)

A. CHANGE DRAFT INFORMATION OR MEMBERSHIP TYPE

Bank Draft

Change in Bank Draft

A staff member will contact you for your bank information.

Credit Card Draft

Change in Credit Card Draft

A staff member will contact you for your credit card information.

Change Membership Type:

Change membership type from to

Add or Delete

Name

Age:

Date of Birth:

Gender

NEW ADDRESS/PHONE/EMAIL OR CHANGE OF NAME INFORMATION

New Address:

New Phone Number/Email

Change of Name:

GIVING BACK

The Y is a non-profit organization dedicated to social responsibility, youth development, and healthy living. Would you be interested in giving back to the community by rounding up your monthly dues? Please choose from the following:

Yes, by $4/month

Yes, Other $

No Thanks

SIGNATURE & DATE

I understand and agree to the terms as stated above.

Signature

Date

Verification Code

Reload Image

Membership Change

Bank Draft

Credit Card Draft

Change Membership Type:

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