SPRINGFIELD SWIMMING AND RACQUET CLUB, INC.

  

P.O. Box 5
Springfield, VA 22150-0005
Membership Application

APPLICANT INFORMATION  

Circle Type of Membership for which applying: Family Couple Single

NAME _________________________________________ HOME PHONE # ____________________

ADDRESS ______________________________________ EMERGENCY # _____________________

CITY, STATE, ZIP CODE _______________________________________________________________

Applicant's Primary Email Address _________________________________________________________

(Email address is required to allow you to receive club announcements in a timely manner)

Family Memberships include the parent(s) and all household dependents, please list all below or on separate sheet.

Family Members Date of Birth Relationship to Prospective Member

________________________ _______________ MEMBER (if approved)
________________________ _______________ _______________
________________________ _______________ _______________
________________________ _______________ _______________
________________________ _______________ _______________
________________________ _______________ _______________
________________________ _______________ _______________
________________________ _______________ _______________
________________________ _______________ _______________

SSRC exists for and because of its Members. If your Membership Application is approved, would you be available
to volunteer your time and talent to help the Club? (Circle) Yes No
If so, how would you help SSRC? (Please use separate sheet if needed)

APPLICANT'S SIGNATURE _________________________________ DATE__________________

For Club use only:

_____ New Membership #, if approved

_____ Membership # of recruiting Member, leave blank if none

Initial Membership Fee ____________

Annual Dues ____________
Capital Improvement Fee ____________
Volunteer Fee ____________
Other Fees:______________

BOARD APPROVED: ____________DATE: ____________ PAYMENT METHOD: ____________

 SPRINGFIELD SWIMMING AND RACQUET CLUB, INC.
P.O. Box 5
Springfield, Virginia 22150-0005

2010 Dues and Fees Schedule

INITIAL MEMBERSHIP FEES

Membership – one time expense $100.00

ANNUAL MEMBER DUES AND FEES

Family Membership Dues – Parent(s) and all dependents in household. $575.00
Couple Membership Dues – Couple occupying same household. $475.00
Single Membership Dues $375.00
Each Additional Adult in household $150.00

***SPECIAL OFFER for Summer 2010***

Couple Limited Usage Membership (20 visits) $250.00

Single Limited Usage Membership (15 visits) $200.00

Payment may be made by check or via PAYPAL. For more information, please contact Becky
Campbell at the SSRC Membership Line - (703) 455-6203, via email at
membership@swimspringfield.com, or our website at http://www.swimspringfield.com