The YMCA at Innovation Square: Resident Membership Form

Please complete the form below to request your Resident Membership to the YMCA at Innovation Square. This membership will be at no cost to you and will expire July 31, 2023. You will need to complete a new form to renew your Resident Membership on or after August 1, 2023.

The following form is for residents of Innovation Square only. Filling out this form does not automatically start your Resident Membership. Your membership will be ready for you within 3-5 business days.

First

Last

Address

Apt. Number

City/Town

State/Province

ZIP/Postal Code

Country

Phone Number

Email Address

Please use the same address you have on file with the Innovation Square Leasing Office

Gender

Male

Female

Other

Date of Birth

Emergency Contact First Name

Emergency Contact Last Name

Emergency Contact Phone Number

Ethnicity

Household Income

Membership Agreement

see below

The electronic funds transfer payment plan is a continuous membership plan and I have provided valid account information to permit this account to be charged accordingly. I understand that this electronic funds transfer will remain in effect as long as I meet the terms of this membership agreement.

It is my complete understanding that if I wish to terminate or change my membership in any way, I must give the YMCA a 30-day written notice.
The YMCA, at their discretion, may adjust the monthly rate applicable to my category of membership. I understand that I will receive at least 30 days written notice prior to any such change.

I realize that I am responsible for any payment plus a service charge applied by the YMCA if my membership debit is not honored by my bank or charge card. This is in addition to any service fee my bank may make.

If I think there is an error in my membership debit, I will notify the YMCA within 60 days of the transaction date. The transaction will be investigated and corrected if necessary.

The YMCA of Greater Rochester is not responsible for lost, stolen, or damaged items and/or personal property.

I agree to abide by the rules and regulations of the YMCA, which are designed for the enjoyment of all its members. The protection of members who are utilizing the YMCA is of paramount concern to the YMCA of Greater Rochester. Therefore, we reserve the right to deny access or membership to any person whose behavior is judged to be in conflict with the welfare and safety of other members and/or staff; has pleaded guilty to the transportation of illegal, habit forming or dangerous drugs; or who is presently clearly under the influence of intoxicating beverages or behavior modifying drugs. The YMCA conducts regular sex offender screenings on all members and staff. If a sex offender match occurs, the YMCA reserves the right to cancel membership, end program participation, and remove visitation access.

I hereby consent to and authorize the use and reproduction of any and all photographs or video footage taken of me and/or my family, including children listed on this application, for YMCA of Greater Rochester's promotional and public relations purposes. I understand that will I receive no reimbursement for allowing my photo to be taken or for the use of the photo or video.
The use of cell phones or camera phones is not permitted in the locker rooms, wellness center, gymnasium and other program areas. Photos and videos may be taken only with the expressed permission of YMCA management and all participants being photographed. Signed photo releases must be filed with the YMCA.

Waiver, Release, Indemnification and Hold Harmless Agreement

see below

In consideration for use of wellness facility and the equipment of the YMCA of Greater Rochester (YMCA) and Innovation Partners ROC, LLC, Gallina Development Corp (Gallina), I agree to release, indemnify and hold harmless the YMCA and Gallina, and their officers, employees, and volunteers, with respect to any and all accidents, injuries, losses or damages to person or property that result from my use of the wellness facility, whether arising from the negligence of the YMCA, Gallina or otherwise, to the fullest extent permitted by law. I do further agree on behalf of myself, and my heirs, executors and administrators, to waive, release and forever discharge any and all rights and claims for damages which may have accrued, or which may hereafter accrue, to me arising out of or connected with use of the YMCA and Gallina facilities and property, or use of equipment within the YMCA and Gallina facilities and property.

I understand that even when every reasonable precaution is taken, accidents can sometimes occur. I further understand that the activities have inherent risks of injury and I hereby assume all such risks and hazards incidental to my or my participation in the programs, use of the facilities, or use of equipment within the facilities of the YMCA and Gallina.

Digital Signature

Sign above