Membership Number (Office use only) _______ Bogota Swim Club P.O. Box 66 Bogota, NJ 07603 2015 MEMBERSHIP APPLICATION www.bogotaswimclub.com 201-489-1991 (* indicates required information) * Name _____________________________________________ * Address: _____________________________________City:__________ State: _________ Zip:__________ * Email Address: ____________________________________________________ * Phone #: Home. ____________________________ Cell Phone: ________________________ *Emergency Contact: Name__________________________________ Phone # ___________________________ Mgr. _________ _ * Full name and date of Birth of all household members. Proof of residency required for all adults 18 and older. Please Print Clearly (Additional Family may be listed on the back of this sheet.) First & Last Name Date of birth Relationship To Member ID# Manager Initials Please check type of membership desired: √ Type of membership Family (Family of 5, ea. Additional $25.00 per person) Dues/season Bogota Resident residency required) $500 Single $320 $420 2 Person Membership (Must live in the same household. Proof of residence required.) Weekends only $400 $475 $400 $400 Family Monthly (specify July or August) $440 $440 Senior Single (Must be at least 65 years of age) $250 $250 Senior Couple (Must be at least 65 years of age) $340 $340 (Proof of Dues/season Non - Bogota Resident $575 Member Signature: ________________________________________ Date: ________________ Note: The applicant is responsible for notifying the Club of changes in address or phone #. Proof of Residence: Adult: ___ Driver License ____ Utility Bill ___ Mortgage Statement ___ Rental Agreement Child: ___ Birth Certificate ___ Proof of Guardianship ___ Income Tax Form Manager : _____ How did you learn about us? Friend ___________ Website ___________ Mailer ___________ Other ___________ (Both pages required for application) Payment Record Year Membership Type Payment Amount Payment Type Cash Check Charge _____________________ Cash Check Charge _____________________ Cash Check Charge _____________________ Cash Check Charge _____________________ Cash Check Charge _____________________ Cash Check Charge _____________________ Cash Check Charge _____________________ Cash Check Charge _____________________ Cash Check Charge _____________________ Cash Check Charge _____________________ Mgr/Trustee Initials