Non-Student Application 2011-12

Please print clearly!

First Name Middle Initial Last Name M or F

Employee ID # ( 9 digits) / Recreation Card ID#

Home Address, Apt. no.

City, State and ZIP Code

Email Address

Campus Department and Campus Mail Code (6 digits)

Daytime Phone Number

Home Phone Number

IF YOU ARE PURCHASING ADDITIONAL FAMILY MEMBERSHIPS, PLEASE COMPLETE INFORMATION BELOW
Household Adults Full Name M or F Dependents Full Name M or F Dependents Full Name M or F DOB / / DOB / / Dependents Full Name M or F DOB / / Dependents Full Name M or F DOB / / Household Adults Full Name M or F

Payment:

Total amount purchased: _____________

CASH BRUIN CARD # ________________ Discover AMEX EXP: ____/____/____

PAYROLL DEDUCTION Annual Services only Please complete Payroll Deduction Authorization Form. Employee ID # _________________________ I elect to have $__________ per month deducted from my payroll earnings for the purchase of Recreation Privileges in perpetuity until I submit written notice of cancellation. I have read, and agree to the Payroll Deduction Terms and Conditions on the attached Payroll Deduction Authorization form.
_______________________________________________________________________________

CHECK#________ CHARGE: Visa

Mastercard

CARD # ______________ ______________ ______________ _____________ __________________________________________________________________________

SIGNATURE I agree to pay the above total amount according to the Card Issuer Agreement DATE

SIGNATURE

DATE

POLICIES for Refunds, Transfers & Payroll Deduction Cancellation

RECREATION MEMBERSHIP REFUND POLICY: Membership card(s) must be surrendered when submitting a refund request form. No refunds for short-term memberships (less than 12 months). Annual memberships paid up front are refunded for of the following reasons, are subject to a one month cancellation fee and require documentation: Termination of employment; Transfer off-campus; Formal leave of absence and sabbaticals; Changes in medical condition resulting in physical limitations. After one year of membership, annual memberships refunded for any reason are subject to a one month cancellation fee if there is no break in membership. Payroll deduction memberships may be cancelled at any time with 30 day written notice. No refunds are issued on Payroll Deduction. FITNESS PASS: Fitness Pass must be surrendered with the refund request. There are no refunds for quarter passes. Annual Fitness Pass refunds will follow the Membership Refund Policy. LOCKERS: A 50% refund will be given only for the cancellation of an annual locker rental within 6 months of purchase. The locker must be cleared. No refunds will be issued for short-term rentals. Signature_________________________________________________________________ Date __________________________________________

Please Note: This application is subject to verification of eligibility for membership according to
UCLA Recreation Card Sale Policy. Your membership is subject to cancellation should you now or in the future not meet these eligibility requirements. Neither a Recreation Membership nor a Bruin Card I.D. may be transferred to another person. Violation of this policy may result in confiscation of the Recreation Membership Card and the suspension of recreation/membership privileges. All users agree to comply with University and UCLA Recreation policies, procedures, posted instructions, and direction given by a UCLA Recreation employee. Failure to comply may result in confiscation of the Recreation Membership Card and loss of recreation/membership privileges.

Office Use Only:

____/_____/_____ Locker Clearance ____/_____/_____ Fitness Pass Exp _______________ Receipt# ______________ Staff Initials

____/_____/_____ Todays Date ____/_____/____ Start Date ____/_____/_____ Exp Date

Non-Student Application 2011-12

UCLA AFFILIATION
*requires Alumni Association Membership

Campus Affiliations
Faculty (Emp) Staff (Emp) Emeritus (Eme) (Retired Employees) Young Alumni* (YA) (Graduated 2007-10) Other Specify____________________

Alumni Affiliations (Alu)

UCLA Alumni* Patient Major Donor Other Specify____________________

Other Affiliations (OA)

UCLA Affiliate* Campus Visitor Other Specify____________________

PASSPORT OPTIONS Passport (1): Blue Gold Passport (2): Premier Passport (3): Bruin Family (BFam): Sunset Seasonal Family (SFam): Youth Activity Pass: # of youth ______ x $______ /month $______ /month x x # of months ______ = # of months ______ = # of adults ______ # of adults ______ # of adults ______ x x x $______ /month $______ /month $______ /month x x x # of months ______ = # of months ______ = # of months ______ = $___________ $___________ $___________ $___________ $___________ $___________

SELECT ZONE Central Campus (Cc) Sunset Park (Ss) Recreation South (Rs)
Opening Fall 2011!

LOCKER RENTAL JWC Mens Locker JWC Womens Locker SAC Mens Locker SAC Womens Locker SCRC Mens Locker SCRC Womens Locker North Pool Mens Locker North Pool Womens Locker Locker Clearance OTHER RECREATION SERVICES

$5 $5 $5 $5 $5 $5 $5 $5

x x x x x x x x

# of months ______ # of months ______ # of months ______ # of months ______ # of months ______ # of months ______ # of months ______ # of months ______ $5

= = = = = = = = =

$___________ $___________ $___________ $___________ $___________ $___________ $___________ $___________ $___________ Office Use Only

Quarter Adult Fitness Pass # of adults ______ x $25 x # of qtrs ______ Annual Adult Fitness Pass (rate applicable from 6/1/11 5/31/12 ONLY) # of adults ______ x $72 Yoga Pass Adult (quarter only) $25 Pilates Addendum (quarter only) $20 Fitness Pass Replacement $25 $90 $54 $30 $60 $329 $116 $112 $25 TOTAL AMOUNT

= =

$___________ $___________ $___________ $___________ $___________ $___________ $___________ $___________ $___________ $___________ $___________ $___________ $___________ $___________

Monthly (Mo) Annual (Yr)

Guest Pass Punchcards Adult Guest Pass Punchcard (10 passes included) Junior Guest Pass Punchcard (10 passes included) Commuter Passport Shower (SAC Only) Shower and Locker (SAC Only) Parking NTV Parking one per family (valid thru 6/30/12) RC Brown one per family (valid thru 9/30/11) Bruin Masters Swim Addendum (valid thru 6/30/12) Membership Card Replacement

_________________________ Membership Code _________________________ Guest Pass #s _________________________ PFT Consultation #s _________________________ Fitness Pass #s _________________________ Yoga Pass #s _________________________ Parking

PARTICIPANT EXPECTATIONS
Please sign and return with your renewal forms. This document is availabe at www.recreation.ucla.edu

UCLA Students, Faculty, Staff, Members and Guests of UCLA Recreation facilities and programs are expected to behave with civility and appropriate conduct. By use of these facilities and programs, you agree to comply with the Participant Expectations and cooperate with staff while utilizing our facilities, programs and services. The Goal of the Participant Expectations is to create and foster a community that is as safe and welcoming as possible to each individual community member. All students, staff, members and guests are encouraged to exercise good judgment in caring for the safety of others as well as themselves. In the event you witness or experience threatening or inappropriate behavior by another individual, please report the situation immediately to appropriate staff. Our Participant Expectations encompass the examples outlined below. The following types of conduct are among those that are specifically prohibited and may result in loss of membership, a report to the Dean of Students office and/or University police: AGGRESSIVE, UNSAFE OR RECKLESS BEHAVIOR: Aggressive, unsafe or reckless behavior is explicitly forbidden in UCLA Recreation facilities and programs. This includes, but is not limited to, the following: Promoting or engaging in physical abuse, verbal abuse, threats, intimidation, harassment, coercion and/or other conduct which threatens or endangers the health or safety of any person. The use of fighting words to harass any employee or guest in connection with official University functions or University sponsored programs is also prohibited. UNAUTHORIZED ENTRY: A valid membership or pass is required for access to all UCLA Recreation facilities and programs. In addition, entering unauthorized areas such as offices, gender opposite locker rooms and maintenance workshops without the express permission of UCLA Recreation will be considered trespassing. FORGERY: Sharing identification cards for access into UCLA Recreation facilities or programs is considered forgery. Forgery, altering identification cards, providing false information in connection with a membership application or program form, or unauthorized use or misuse of any University document, record, key, electronic device, or identification is strictly prohibited. SOLICITATION: Guest sponsorship privileges provide our eligible members the opportunity to share use and enjoyment of UCLA Recreation facilities and programs with individuals with whom they have an established relationship. In the interest of the safety of all users, members should refrain from sponsoring individuals who are unknown to them and to report any solicitations to do so to UCLA Recreation staff. COMPLIANCE: All users must comply with posted instructions or signs and with the directions of UCLA Recreation staff, University official(s) or other public official(s) acting in the performance of their duties. DISORDERLY CONDUCT: Engaging in disorderly or lewd conduct, including being under the influence of alcohol or controlled substances, is strictly prohibited. PHOTOGRAPHY AND VIDEO TAPING: Photography or videotaping of individuals in or images of the facilities must have prior Department and campus approval. UNAUTHORIZED COMMERCIAL ACTIVITY: Posting, advertising, conducting unauthorized private lessons or training, soliciting individuals in UCLA Recreation facilities for personal services, businesses, or agencies is strictly prohibited.

The following actions are considered Criminal Activity and will result in immediate police action. UCLA Recreation staff will contact University police and request assistance addressing the immediate threat. Additional sanctions and restrictions may apply including a loss of privileges and/or a report to the Dean of Students Office. VANDALISM: Damage to or destruction of any property of the University or property of others while on University premises. ASSAULT/BATTERY: Violent verbal or physical attack, or an unlawful attempt or threat to do physical injury to another. THEFT: Removal of or conversion of University property or property of others while on University premises. DANGEROUS WEAPONS: Possession or use of an explosive device, firearm, or other deadly weapon when on the premises.

UCLA Recreation believes it is essential that all people exercise their right to express their human and cultural identities. Consistent with this belief, our programs promote healthy lifestyles and the preservation of human dignity by fostering the spirit of fair play without bigotry, hatred, prejudice or disrespect. I have read and agree to the UCLA Recreation Participant Expectations and join the UCLA Recreation Community in acknowledging and embracing these values. Signature_____________________________________________________________ Date________________________