Applicant Name
Last Name:
First Name:
PennID
Applicant Status:
Address:
Street:
City:
State:
Zip Code:
Work
Telephone:
Home Telephone:
E-mail:
Gender:
Primary Member's Name (if applicant
is Spouse Dependent status, list primary member here )
Last Name:
First Name:
PennID
By paying for membership through payroll deduction you will continue to be
charged unless a written cancellation request is submitted to the
Department of Recreation. All cancellation are subject to a $25 fee.
Contact membership services for cancellation information. Payroll
Deduction cannot be used for Locker Service.
**Payroll deduction is only available to full-time Penn employees. Health System and CHOP employees are not eligible for payroll deduction. Please check below if you are paid weekly or monthly. Deductions for monthly employees will begin with the May 2013 paycheck. The monthly fee will be divided into 4 paychecks. Weekly will be deducted out of your next weekly pay check.
Faculty / Staff Pay Schedule:
Spouse Pay Schedule:
User Agreement/Waiver - By being permitted
access to Recreational Facilities, users acknowledge their agreement
to the following:
Certain risks of injury are inherent to participation in sport
and recreational activities. These types of injuries may be
minor or serious and may result from one's own actions, and
of others, or a combination of both.
Posted or distributed rules and regulations are designed for
the safety and protection of recreational users, who in turn
are responsible to abide by these rules and regulations.
Certain activities require a minimum level of health and fitness
ability. Recreational users warrant being physically fit to
participate in any activities undertaken, and understand a choice
to participate brings with it the voluntary assumption of risks
of injury, which may arise from participation in these activities.
Recreational users agree that the University of Pennsylvania,
its employees and agents shall not be liable for injury to person
or loss or damages to personal property arising form, or in
any way arising, or in any way resulting from the participation
in these activities, unless such injury is caused by the sole
negligence of the University, its employees or agents while
acting within the scope of their duties, and agree to waive
such claims against the University for such injury or loss.
By checking this box,
I acknowledge that I have read and understand the User Agreement/Waiver,
and Payroll Deduction Procedure.