Fill and Sign the Informed Consent for Philips Zoom Ap Tooth Whitening

ANNUAL MEMBER RENEWAL FORM ROCKVILLE CENTER PO Box 111 Rockville, VA 23146 Complete and return this form, along with your payment to the above address, by May 1, 2011. Checks should be made payable to “Rockville Center, Inc.” Household Pool Membership Information Name: _____________________________________________________________________ Address: _____________________________________________________________________ _____________________________________________________________________ Phone(s): _____________________________________________________________________ Email: _____________________________________________________________________ Name Of Primary Household Member: _______________________________________ $265.00** (If member is under 18 yrs of age, must have an adult contractually responsible.) Names of Additional Members in the Household (Each person must reside in the primary member household. Financially independent adult children should purchase their own membership.) NAME RELATIONSHIP AGE 1. 2. 3. 4. 5. 6. 7. 8. $50.00 $50.00 $50.00 $50.00 $0.00 $0.00 $0.00 $0.00 Additional Non-Member Fees: 1. Babysitter – Non-household babysitter may only come while caring for member children 2. Au Pair- Household au pair may only come while caring for member children $100.00 $50.00 Names of Non-Members (Babysitter or Au Pair) added for fee: AGE 1. 2. 3. Annual Membership Form 5/1/11 through 4/30/12 Rev. 2/27/2011 AMOUNT 2011-2012 Payment Summary Annual Pool Membership Dues Inactive Status (Membership with no privileges) -- $75 $_____________ Primary Household Member Dues $265.00** Additional Members in the Household ($50 each, maximum of $200) $_____________ Additional Non-Member Fees $_____________ LATE FEE: If postmarked after 5/1/11, add $35 $_____________ Pool Guest Passes: 10 pool guest passes per booklet for $40 ea. ($50 Value) # of Guest Pass Booklets: _____________ x $40 $_____________ **CASH DISCOUNT: If paying by cash or check, take $15 off your total. $_____________ TOTAL $______________ For Credit Card Payments: ____Visa _____Mastercard Credit Card #: __________________________________________________ Expiration Date: _____________ Name on Card: _________________________________________________ Signature: _________________________________________________________________________________ The following committees are still in need of a chair and committee members. Please consider serving on one of the following: ______Pool Committee ______Fundraising I would like someone to contact me with information about the following: _____Swim Team _______Swim Lessons Do you own or operate a local business and would you be interested in having your business included in a membership database and publicized to the membership? If yes, name & contact info of business: For Rockville Center Use ONLY _____Cash ______ Check# ________ Date Postmarked: ___________ Annual Membership Form 5/1/11 through 4/30/12 Rev. 2/27/2011