Beckerman Recreation Center Dependent Membership Application

Beckerman Recreation Center Dependent Membership Application

Application for a Dependent Membership to the Beckerman Recreation Center. Our Membership Team will create your membership profile and email you when you may come to activate your membership at the Beckerman Recreation Center Welcome Desk.

In order to be eligible for a Dependent Membership you must have a Sponsor. A Sponsor must be a currently active Faculty, Staff, or Student member of the Beckerman Recreation Center.

Please note individuals 15 years of age and younger are not permitted to be sponsored as Dependent Members.

Please visit http://www.newhaven.edu/student-life/health-wellness/chargerrec/membership.php for more membership information.

Sponsor Information

A Sponsor is required to be eligible for a Dependent Membership.
A Sponsor must be a currently Active Faculty, Staff, or Student member of the Beckerman Recreation Center.
Please provide the Spoonsor Member's information below.

Please note: Your Sponsor must be present at the time of activation.

Sponsor Name Sponsor Name First Last

Relation to Sponsor

Sponsor University Email

Sponsor University ID

Profile Information

The Beckerman Recreation Center Membership Team requires the following information to create your membership profile.

Name on ID Name on ID First Last

Preferred Name Preferred Name First Last

Date of Birth Date of Birth / MM / DD YYYY

Individuals 15 years of age and younger are not permitted to be sponsored as Dependent Members.

Permanent Address Permanent Address

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country

Phone Number Phone Number - ### - ### ####

Would you like to opt in for SMS messages from ChargerREC through the RecAuto system?

Would you like to opt in for SMS messages from ChargerREC through the RecAuto system? Yes No I'm not sure

Emergency Contact Emergency Contact First Last

Emergency Contact Phone Number Emergency Contact Phone Number - ### - ### ####

Authorization

I verify and understand the following:

I verify and understand the following: The above information is accurate The above information may be used to create or update my profile for the Beckerman Recreation Center This form does not give access to a Beckerman Recreation Center Membership and the amenities included therein

Name Name First Last

Date Date / MM / DD YYYY

Draw your signature into the box below.

Draw or Type

I understand this is a legal representation of my signature. Clear

Full Name

I understand this is a legal representation of my signature.