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2. Primary Member Information
4. Last Name*
5. First Name*
7. Primary Phone Number*
8. Secondary Phone Number
10. Email Address*
12. Address *
14. City*
15. State*
16. Zip*
20. Hold Request & Policy

    Hold requests require 15-day notice. Membership may be placed on hold for a maximum of three months each calendar year. DRAFTED MONTHLY: Hold begins and ends on the current draft date (1st or 15th of month).  ANNUAL MEMBERSHIP: Hold begins and ends on the 1st of the month. All hold requests will be charged a $25 administration fee.

22. Hold to be effective for (please check one):*

    1. 1 month
    2. 2 months
    3. 3 months
24. Start Month*
    -- Select One --JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecember
25. Start Date (please check one)*

    1. 1st of the month
    2. 15th of the month
27. Membership Type (Check all that apply)*

    1. Adult
    2. Family
    3. Youth/Teen

    1. Special Hours
    2. Special Hours Couple
    3. Adult Plus*
29. *List each Adult Plus or Splash Aquatics member under your account.
31. Reason for Hold*
    -- Select One --Temporary RelocationFinancialTravel/VacationSchedule ChangesSplash Season PauseOther (please describe below)
33. Other Reason for Hold
35. Confirmation
37. Comments
39. Acknowledgement Required: *

    1. I authorize the CRC to draft $25 from my bank account for an administrative fee
    2. I understand the CRC is placing my membership on hold beginning and ending on my scheduled draft date.
    3. I acknowledge that my membership dues will not be charged during my membership Hold.
    4. I understand that my membership billing will automatically resume at the end of the hold period.
41. Member Signature*
    Please type name to sign.
43. Please include date and time
    Please include date and time

    Please include date and time
Leave This Blank:


45. 1. Receive an email copy of this form.
46. Email address

    This field is not part of the form submission.

47. Submit

* indicates a required field