8/3/2019 Non Student Membership

1/3

Non-St udent Ap pl ic at ion 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

( ) ( )

F YOU ARE PURCHASING ADDITIONAL FAMILY MEMBERSHIPS, PLEASE COMPLETE INFORMATION BELOW

Household Adults Full NameM or F

Household Adults Full NameM or F

Dependents Full Name

M or F DOB / /

Dependents Full Name

M or F DOB / /

Dependents Full NameM or F DOB / /

Dependents Full NameM or F DOB / /

Payment: Total amount purchased: _____________

CHECK#________ CASH BRUIN CARD # ________________

CHARGE: Visa Mastercard Discover AMEX EXP: ____/____/____

CARD # ______________-

______________-

______________-

_____________

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

POLICIES for Refunds, Transfers & Payrol l Deduct ion Cancel lat ion

ECREATION MEMBERSHIP REFUND POLICY:Membership card(s) must be surrendered when submitting a refund request form. No refunds for sh ort-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-ca

ormal 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 subjecne month cancellation fee if there is no break in membership.ayroll deduction memberships may be cancelled at any time with 30 day written notice. No refunds are issued on Payroll Deduction.

TNESS PASS:itness Pass must be surrendered with the refund request. There are no refunds f or quarter passes. Annual Fitness Pass refunds will follow the Membership Refund Policy.

OCKERS:A50% 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 s hort-term rentals.

PAYROLL DEDUCTIONAnnual Services only Please complete Payroll DeductionAuthorization Form.

Employee ID # _________________________

I elect to have $__________ per month deducted from my payroll earnings for the purchasof Recreation Privileges in perpetuity until I submit written notice of cancellation. I have reand agree to the Payroll Deduction Terms and Conditions on the attached Payroll DeductiAuthorization form.

_______________________________________________________________________________

SIGNATURE DATE

Please Note: This application is subject to verification of eligibility for membership according toUCLA Recreation Card Sale Policy. Your membership is subject to cancellation should you now or in thefuture not meet these eligibility requirements.

Neither a Recreation Membership nor a Bruin Card I.D. may be transferred to another person. Violation ofthis policy may result in confiscation of the Recreation Membership Card and the suspension ofrecreation/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

____/_____/_____ ____/_____/_

Todays Date Fitness Pass Exp

____/_____/____ __________

Start Date Receipt#

____/_____/_____ ___________

Exp Date Staff Initials

Signature_________________________________________________________________ Date __________________________________________

8/3/2019 Non Student Membership

2/3

Non-St udent Ap pl ic at ion 2011-12 CLA A FFILIATIONequires Alumni Association Membership

ampus Affiliations Alumni Affiliations (Alu) Other Affiliations (OA)

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

UCLA Alumni*PatientMajor DonorOther Specify____________________

UCLA Affiliate*Campus VisitorOther Specify____________________

ASSPORT OPTIONS

Blue Passport (1): # of adults ______ x $______ /month x # of months ______ = $___________

Gold Passport (2): # of adults ______ x $______ /month x # of months ______ = $___________

Premier Passport (3): # of adults ______ x $______ /month x # of months ______ = $___________

Bruin Family (BFam): $___________

Sunset Seasonal Family (SFam): $______ /month x # of months ______ = $___________

Youth Activity Pass: # of youth ______ x $______ /month x # of months ______ = $___________

OCKER RENTAL

JWC Mens Locker $5 x # of months ______ = $___________ JWC Womens Locker $5 x # of months ______ = $___________

SAC Mens Locker $5 x # of months ______ = $___________

SAC Womens Locker $5 x # of months ______ = $___________

SCRC Mens Locker $5 x # of months ______ = $___________

SCRC Womens Locker $5 x # of months ______ = $___________

North Pool Mens Locker $5 x # of months ______ = $___________

North Pool Womens Locker $5 x # of months ______ = $___________

Locker Clearance $5 = $___________OTHER RECREATION SERVICES

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 $___________Guest Pass Punchc ards

Adult Guest Pass Punchcard (10 passes included) $90 $___________ Junior Guest Pass Punchcard (10 passes included) $54 $___________Commuter Passport

Shower (SAC Only) $30 $___________ Shower and Locker (SAC Only) $60 $___________

arking

NTV Parkingone per family (valid thru 6/30/12) $329 $___________ RC Brownone per family (valid thru 9/30/11) $116 $___________ Bruin Masters Swim Addendum(valid thru 6/30/12) $112 $___________ Membership Card Replacement $25 $___________

TOTAL AMOUNT $___________

SELECT ZONE

CentralCampus (CcSunset Park (Ss)

Recreation South (RsOpening Fall 2011!

Office Use Only

Monthly (Mo)

Annual (Yr)

________________________

Membership Code

________________________

Guest Pass #s

________________________

PFT Consultation #s

________________________

Fitness Pass #s

________________________

Yoga Pass #s

________________________

Parking

8/3/2019 Non Student Membership

3/3

UCLA Students, Faculty, Sta, Members and Guests of UCLA Recreaon facilies and programs are expected to behave wcivility and appropriate conduct. By use of these facilies and programs, you agree to comply with the Parcipant Expectaoand cooperate with sta while ulizing our facilies, programs and services.

The Goal of the Parcipant Expectaons is to create and foster a community that is as safe and welcoming as possible to eacindividual community member. All students, sta, members and guests are encouraged to exercise good judgment in caringfor the safety of others as well as themselves. In the event you witness or experience threatening or inappropriate behavior b

another individual, please report the situaon immediately to appropriate sta. Our Parcipant Expectaons encompass theexamples outlined below. The following types of conduct are among those that are specically prohibited and may result inloss of membership, a report to the Dean of Students oce and/or University police:

AGGRESSIVE, UNSAFE OR RECKLESS BEHAVIOR:Aggressive, unsafe or reckless behavior is explicitly forbiddenin UCLA Recreaon facilies and programs. This includes,but is not limited to, the following: Promong or engagingin physical abuse, verbal abuse, threats, inmidaon,harassment, coercion and/or other conduct which threatensor endangers the health or safety of any person. The useof ghng words to harass any employee or guest inconnecon with ocial University funcons or University

sponsored programs is also prohibited.

UNAUTHORIZED ENTRY:A valid membership or pass is required for access to all UCLARecreaon facilies and programs. In addion, enteringunauthorized areas such as oces, gender oppositelocker rooms and maintenance workshops without theexpress permission of UCLA Recreaon will be consideredtrespassing.

FORGERY:Sharing idencaon cards for access into UCLA Recreaonfacilies or programs is considered forgery. Forgery,altering idencaon cards, providing false informaon inconnecon with a membership applicaon or program form,or unauthorized use or misuse of any University document,record, key, electronic device, or idencaon is strictlyprohibited.

SOLICITATION:Guest sponsorship privileges provide our eligible membethe opportunity to share use and enjoyment of UCRecreaon facilies and programs with individuals wwhom they have an established relaonship. In the intereof the safety of all users, members should refrain frosponsoring individuals who are unknown to them and report any solicitaons to do so to UCLA Recreaon sta.

COMPLIANCE:All users must comply with posted instrucons or sigand with the direcons of UCLA Recreaon sta, Universocial(s) or other public ocial(s) acng in the performanof their dues.

DISORDERLY CONDUCT:Engaging in disorderly or lewd conduct, including beiunder the inuence of alcohol or controlled substances,strictly prohibited.

PHOTOGRAPHY AND VIDEO TAPING:Photography or videotaping of individuals in or imagof the facilies must have prior Department and camp

approval.

UNAUTHORIZED COMMERCIAL ACTIVITY:Posng, adversing, conducng unauthorized privalessons or training, solicing individuals in UCLA Recreafacilies for personal services, businesses, or agenciesstrictly prohibited.

UCLA Recreation believes it is essential that all people exercise their right to express their human and culturidentities. Consistent with this belief, our programs promote healthy lifestyles and the preservation of human digniby 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 acknowledging and embracing these values.

Signature_____________________________________________________________ Date_______________________

The following acons are considered Criminal Acvity and will result in immediate police acon. UCLA Recreaon sta wcontact University police and request assistance addressing the immediate threat. Addional sancons and restricons mapply including a loss of privileges and/or a report to the Dean of Students Oce.

VANDALISM:Damage to or destrucon of any property of the Universityor property of others while on University premises.

ASSAULT/BATTERY:Violent verbal or physical aack, or an unlawful aempt orthreat to do physical injury to another.

THEFT:Removal of or conversion of University property or propeof others while on University premises.

DANGEROUS WEAPONS:Possession or use of an explosive device, rearm, or othdeadly weapon when on the premises.

PARTICIPANT EXPECTATIONSPlease sign and return with your renewal forms. This document is availabe at www.recreaon.ucla.e