Membership Form

Fill out the Membership form and bring it to the Greenwood Community Center to complete registration.

Membership Application

Primary Membership Pass #:

Date: New/Renewal: Resident Non-Resident Proof of Residency ___________ Check #_______________ Cash __________ Credit ____________ Amount/Trans # ______________ / _______________

Household Primary: Household Address: City/ State/ Zip: Primary Phone: Email: Work Phone:

Additional Membership Information:

Silver Sneakers #_________________________________ Renew Active #______________________________ Prime #_________________________________________ Military

Membership Information (in same household)

Membership Type Payment Type

Primary Family Member #1 Family Member #2 Family Member #3 Family Member #4 Family Member #5 Family Member #6 Name Age D.O.B.

Kid City The GYM Fieldhouse Annual, Paid in Full 3-month, Paid in Full (The GYM Only) Installment Billing – 12 monthly payments

Emergency Contact Information

Emergency Contact Phone

Is there any special health information you would like to disclose about any member of your household?

P A R K S & R E C R E A T I O N D E P A R T M E N T

100 Surina Way Greenwood, IN 46142 317.881.4545