Please enable JavaScript in your browser to complete this form.Member Name *FirstLastEmail *Primary Phone *Address *Address Line 1Address Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeMember 1 Date of Birth *Member 1 Gender Identification FemaleMaleTrans*Genderqueer/nonconformingDecline to sayEmergency Contact Name *FirstLastEnter the name of a person to contact in case of emergency. If you don't have a contact, please type None into the First and Last boxes.Emergency Contact Phone NumberMembership Type *IndividualFamilySelect a membership type based upon your needs. Individual memberships are for a single person. Family memberships are for valid for two adults and/or up to 6 children (under 21) or adult dependents who reside in the same household. Membership Level (Individual) *Participating - $ 60.00Sustaining: Bronze Level - $ 200.00Sustaining: Silver Level - $ 500.00Sustaining: Gold Level - $ 1,000.00Select a membership level. Any funds paid above the cost of a one year participating membership are tax deductible. Sustaining Members receive a donation letter acknowledging the generous contribution made in support of ESCC programs and operations.Membership Level (Family) *Participating - $ 100.00Sustaining: Bronze Level - $ 200.00Sustaining: Silver Level - $ 500.00Sustaining: Gold Level - $ 1,000.00Select a membership level. All Sustaining Memberships receive a tax donation letter noting the generous contribution made in support of ESCC programs and operations.Additional Family Members *123456Not counting you, how many additional people will be on the membership?Name - Additional Member 2 *FirstLastDate of Birth - Additional Member 2 *Gender Identification - Additional Member 2 *FemaleMaleTrans*Genderqueer/nonconformingDecline to sayName - Additional Member 3 *FirstLastDate of Birth - Additional Member 3 *Gender Identification - Additional Member 3 *FemaleMaleTrans*Genderqueer/nonconformingDecline to sayName - Additional Member 4 *FirstLastDate of Birth - Additional Member 4 *Gender Identification - Additional Member 4 *FemaleMaleTrans*Genderqueer/nonconformingDecline to sayName - Additional Member 5 *FirstLastDate of Birth - Additional Member 5 *Gender Identification - Additional Member 5 *FemaleMaleTrans*Genderqueer/nonconformingDecline to sayName - Additional Member 6 *FirstLastDate of Birth - Additional Member 6 *Gender Identification - Additional Member 6 *FemaleMaleTrans*Genderqueer/nonconformingDecline to sayName - Additional Member 7 *FirstLastDate of Birth - Additional Member 7 *Gender Identification - Additional Member 7 *FemaleMaleTrans*Genderqueer/nonconformingDecline to sayTotal Amount$ 0.00Checkboxes *I certify that, to the best of my knowledge, the above information provided is true and correct.I have read, understand, and agree to the terms of membership.Suspension/Termination of Membership: The Eureka Springs Community Center (herein referred to as “ESSC”) has the right to suspend and/or terminate any membership for behavior unfavorable to the enjoyment of the facilities, services, and programs of the ESCC. Cancellation/Termination of Membership: All annual memberships must be paid in advance and are not eligible for cancellation. Release and Waiver of Liability and Indemnity Agreement: In consideration for being permitted to utilize the facilities, services, and programs of the ESCC for any purpose, including but not limited to observation or use of facilities or equipment, participation in any program affiliated with the ESCC, the undersigned, for oneself, any personal representatives, heirs, and next of kin, hereby acknowledges, agrees and represents that one has, or immediately upon entering or participating will inspect and carefully consider such premises and facilities or the affiliated program. It is further warranted that such entry into the ESCC for observation or use of any facilities or equipment or participation in such program constitutes an acknowledgment that such premises and all facilities and equipment therein and such affiliated programs have been inspected and carefully considered and that the undersigned finds and accepts same as being safe, and reasonably suited for observation, use or participation. THE UNDERSIGNED IS THE DESIGNATED REPRESENTATIVE FOR THEIR OWN BEHALF. IF THE UNDERSIGNED IS MARRIED OR COUPLED, THEIR SPOUSE/PARTNER MUST SIGN SEPARATELY. IF PRIMARY UNDERSIGNED IS A PARENT OR GUARDIAN, PRIMARY PARENT/GUARDIAN MUST SIGN ON BEHALF OF THEIR CHILDREN OR WARDS. The undersigned and HEREBY AGREES TO THE FOLLOWING for oneself and all represented individuals: 1. The undersigned hereby releases, waives discharges and covenants not to sue the Eureka Springs Community Center, the Eureka Springs Community Center Foundation, and any associated directors, officers, employees, and agents from all liability to the undersigned, their personal representatives, assigns, heirs, and next of kin for any loss or damage, and any claim or demands therefore on account of injury to the personals or property or resulting in death of the undersigned, whether caused by the negligence of the releases or otherwise while the undersigned is in, upon, or about the premises or any facilities or equipment thereon, or participation in any program affiliated with the Eureka Springs Community Center. 2. The undersigned hereby agrees to indemnify and save and hold harmless the releases and each of them for any loss, liability, damage, or cost they may incur due to the presence of the undersigned in, upon, or about the ESCC premises or in any way observing or using any facilities or equipment of the ESCC whether caused by the negligence of the releases or otherwise. 3. The undersigned hereby assumes full responsibility for any risk of bodily injury, death or property damage due to negligence of releases or otherwise while in, about, or upon the premises of the ESCC and/or while using the premises or any facilities or equipment thereon or participation in any programs affiliated with the ESCC. 4. I, the undersigned, authorize any and all necessary medical and surgical treatment, x-ray, laboratory, anesthesia, ambulance, emergency room treatment, and any and all other medical and /or hospital procedures as may be deemed necessary as prescribed by the attending physician and / or paramedics for myself if I am unconscious and/or if the emergency contact person is not designated or cannot be reached during an emergency. Media Release *Yes - I grant permission to the ESCC.No - I deny permission to the ESCC.Granting media permission allows images and/or digital recordings of me or my family to be used by the ESCC for display, distribution, or publication.Consent Signature - Member 1 *Clear SignatureYour electronic signature is an agreement to the terms and a certification of the trueness of the information given.Consent Signature - Member 2Clear SignatureSignature of the second adult on the membership is required for consent to terms. If this member is unavailable for signature at this time, then the membership card will be held for signature at the front desk.Comment or MessagePlease let us know if you have any questions or concerns. Submit