Waitlist Application – Pearl River Nauraushaun Swim Club

Date of Application:*

Billing Contact Name*

Enter the name of the person who should be contacted regarding any questions about the account.

First Last

Address*

Street Address City State ZIP Code

Occupation:*

Employer:*

Spouse Name:

Spouse Phone:

Spouse Employer:

Please list Children (under 21) with their DOB

A regular membership may only be issued to the head of household. A household is defined in the PRNSC bylaws as a family permanently living together consisting of a head of household, spouse, all unmarried children who have not turned 21 by July 1 of the current year, and all adult dependents living in the household who are not self-supporting because because of a permanent disability. Associate memberships are available to children of the household that are over the age of 21, a mother, father or mother-in-law or father-in-law not gainfully employed and living permanently with the regular member.

Phone*

Email*

Username*

This is what you will use to log into your waitlist account.

Password*

Enter Password Confirm Password

Strength indicator

Select a password that you will use to access your account. You will be able to send a password reset link to the email address you entered above if necessary.

1. Identification:*

Accepted file types: jpg, jpeg, png, gif.

Please upload a photocopy of a picture identification for example a driver's license.

2. Proof of Residency:*

Max. file size: 10 MB.

Please provide two forms of proof of residency in the form of bills that include your address within the Pearl River Fire District or Pearl River School District. Examples include: tax bill, utility bill, water bill or phone bill.

Credit Card

American Express

Discover

MasterCard

Visa

Card Number Expiration Date Security Code Cardholder Name

3. Waitlist Fee*

Price:

Wait list fee: $75.00+ tax (8.375%)

Convenience Fee*

Price:

Total

$0.00

CAPTCHA

Terms of Service*

I hereby apply for membership in the Pearl River-Nauraushaun Swim Club, Inc. I certify that I am at least 21 years of age and reside at the address shown above which is in the Pearl River Fire District or Pearl River School District. I understand that upon receipt of this application, proof of residency, and payment for $81.28, my name will be placed on a list of potential members. I understand that the waiting list may exceed three years. I understand that my wait list payment fee is non refundable. It is my responsibility to keep the Club informed of any change in my address, phone number or email address.

I agree to the Terms of Service

Name

This field is for validation purposes and should be left unchanged.

Wait List Application

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