Perryton Activity Center
Perryton Activity Center

*Please read page two (2) for details regarding categories, rates, and general PAC rules
All available information is needed.
 (*required information for online form)


Family Membership Application
 Monthly Payment Plan / $42.00
 
Personal Information:
First Name* MI Last Name* Gender MF
Mailing Address* City ST Zip*
Home Phone Work Phone Cell Phone
Employer Driver’s License #
E-Mail Address Birth Date*
Friend/Relative Name* Phone* (for emergency)

Spouse:
First Name MI Last Name
Birth Date*//  Driver’s License #
Employer Work Phone

Children:(18 and under only, for other dependents inquire at front desk)
Name Age Birth Date*//
Name Age Birth Date*//
Name Age Birth Date*//
Name Age Birth Date*//
Name Age Birth Date*//

 

*I have read (page 2), understand, and will follow the rules and policies set forth by the Perryton Activity Center and its Board of Directors. I understand that penalties for breaking policies may result in termination of membership. I attest that the information concerning membership is true and correct. Furthermore, I agree to release the Perryton Activity Center, its Board of Directors, employees, and contractors, collectively and individually from any and all liability resulting from the use of the facility by myself or any of my family members.
I have read and agree to the above terms.

The Perryton Activity Center is a private, non-profit organization.
It reserves the right to refuse or take away membership for any reason deemed necessary.

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