Member Information Form

Membership Type^*

Last Name^*

First Name^*

Middle Initial

E-Mail Address^*

Phone Number^*

Birthdate^*

Gender^*

Emergency Contact Name^*

Contact Phone Number^*

Contact Relation^*

Membership Period^*

I HEREBY UNDERSTAND THAT THIS AGREEMENT IS BINDING FOR THE LENGTH OF TIME OF MY MEMBERSHIP AND IS NON TRANSFERABLE AND NON REFUNDABLE. I understand that my membership privileges are subject to suspension or cancellation due to inappropriate behavior, as determined by the Student Life & Wellness Center and guidelines. I understand that I must inform the Student Life & Wellness Center Control Desk of any changes in my membership classification, at any time that such changes occur (i.e. spouse of faculty/staff member who no longer works for UVU or enrolling as an UVU student). I will be responsible for all charges/payments that occur prior to notifying the Student Life & Wellness Center Control Desk of any changes to my membership type.

By continuing this application I hereby acknowledge that I have read and understand the membership procedures form and consent to the above terms.