FILL OUT THIS FORM AND MAIL IT IN OR DROP IT OFF ALONG WITH YOUR PAYMENT.
CHECKS OR CASH ACCEPTED. WE WILL ENTER THE KEYTAG NUMBERS.
MAIL TO: Tri-Valley Fitness Center 36 E. Muskingum Ave. Dresden OH 43821
Tri-Valley Fitness Center Membership/ Renewal
_____New Membership _____Renewal
Primary Member’s Name: _______________________________ Keytag# __________________
Best Phone #: ______________________
E-Mail Address: _____________________________________________________
Emergency Contact’s Name: ________________________ Phone: ______________
Membership Type for This Purchase:
Family*** Single Senior
______ ($167.00) District ______($67.00) District ______($60.30) District
______($334.00) Non-Dist. ______($134.00) Non-Dist. ______($120.60) Non-Dist.
_______Primary Member is a Tri-Valley Employee (No charge for a single employee membership!)
***If Primary Member is a Tri-Valley employee, you are entitled to a 50% discount off
of the listed Membership rate for Family.
If this applies, please apply the deduction in the space for “amount due,”below.
If this is a Family*** Membership, please list add-on members here:
1) _____________________________ Keytag #: __________________
2) _____________________________ Keytag #: __________________
3) _____________________________ Keytag #: __________________
4) _____________________________ Keytag #: __________________
5) _____________________________ Keytag#: __________________
***ALL “family” members must reside at the same address. No exceptions, please.
Total Amount Due For Membership: $__________________ Method: ______cash ______check
By signing below, I knowingly waive and release the Tri-Valley Fitness Center,
Tri-Valley School District, and any and all agents or employees of this District
from any and all claims, causes of action, suits and related rights for myself,
my listed family members, my heirs, administrators, executors, etc. for any
and all injuries, illnesses and damages that might be sustained by myself or any
of my listed family members as a result of participation in any activity or event
at the Tri-Valley Fitness Center. I also state that all individuals associated with
this membership are in satisfactory health and are safely able to participate in
activities at the Tri-Valley Fitness Center.
Primary Member’s Signature: ________________________________________ Date: ______________________________