Online Membership Signup - Bangor Region YMCA

Bangor Region YMCA Online Membership Application

Thank you very much for your interest in joining the Bangor Region YMCA! Please fill out the following membership application, and a Member Experience Associate will contact you promptly to schedule your New Member Orientation! If you have any questions, please don't hesitate to call us at (207) 941-2808.

First Name(Required)

Middle Initial

Last Name(Required)

Primary Phone Number(Required)

Secondary Phone Number

Date of Birth(Required)

Your Email Address(Required)

You will receive email updates about the Bangor Region YMCA as well as access to your online account with your email address. Set up your online account at the Welcome Center Desk or go to BangorYMCA.org.

Mailing Address(Required)

Street Address Address Line 2 City State ZIP Code

Which Membership Type are you signing up for?(Required)

PLEASE NOTE: No payment information is being collected through this form. Payment will be collected at your New Member Orientation, and a staff member will be in touch to answer any questions you may have! PLEASE REMEMBER: We offer Military, Veteran, and First Responder discounts, along with financial assistance to those who qualify. Just Ask!

You've selected a membership that will cover multiple people. Would you like to enter their information now?(Required)

Yes

Please enter the following information for each additional person who will be covered under your membership. Click the plus (+) to the right of the row to add an additional person.(Required)

First & Last Name

Relation to Primary Member

Gender (M/F/U)

Date of Birth (MM/DD/YYYY)

Please check the services offered at the Bangor Region YMCA, which are of interest to you:(Required)

Please check as many services as you like, and we'll be sure to provide you with information about the services that interest you. Many of these services are included FREE with your membership!

Gender

Race

African American

Alaskan Native

Asian/Pacific Islander

Hispanic/Latino

Native American

Caucasian

Other

Prefer Not To Answer

Annual Household Income

$0 - $13,999

$14,000 - $24,999

$25,000 - $39,999

$40,000 - $54,999

$55,000 - $74,999

$75,000 & Over

Prefer Not to Share

Are you interested in financial assistance to help with the cost of your membership?

Yes

I'm not sure

(If yes, one of our Member Experience Associates will share the available financial assistance information with you at your New Member Orientation!)

Your Employer

Business Phone

Your Emergency Contact's Name(Required)

Your Emergency Contact's Relation to You(Required)

(ie: Friend, Spouse, Domestic Partner, Mother, Father, etc.)

Your Emergency Contact's Phone Number(Required)

Were you referred to the Bangor Region YMCA by someone?

Yes

Referred by (Name)

Is there anything else you'd like to share with us?

Consent & Waiver(Required)

I Agree (By checking "I Agree", you are confirming that you have read, and you agree to, the communication and liability waiver listed below.)

I agree to share the information I've entered in this form with the Bangor Region YMCA, and I agree to be contacted by the Bangor Region YMCA using any of the contact information I've provided.

In consideration of gaining membership or being allowed to participate in the activities and programs of The Bangor Region
YMCA and to use its facilities, equipment, and machinery in addition to the payment of any fees or charge, I do hereby waive,
release, and forever discharge The Bangor Region YMCA and its officers, agents, employees, representatives, executors, and all
others from any and all responsibilities or liability for injuries or damage resulting from my participation in any activities or my
use of equipment or machinery in the above mentioned facilities or arising out of my participation in any activities at said facility.
I do also hereby release all of those mentioned and any others acting upon their behalf from any responsibility or liability for any
injuring or damage to myself, including those caused by negligent act or omission of any of those mentioned or others, acting on
their behalf or in any way arising out of or connected with my participation in any activities of The Bangor Region YMCA or the
use of any equipment at The Bangor Region YMCA. I agree to adhere to all policies set by The Bangor Region YMCA as written
in The Bangor Region YMCA code of conduct. I give permission to The Bangor Region YMCA to use photographs and or videos
of myself and above listed family members for the promotion, public relations, records, or other legitimate purposes. I fully
understand that there is no monetary payment to be made to me or anyone else.

The Bangor Region YMCA considers it of great importance to provide a safe and threat-free environment. For
this reason, The Bangor Region YMCA monitors the sexual offender registry. Persons on the list will not be eligible for YMCA
membership, program participation, volunteer or employment opportunities with this YMCA.