Register Online - Social - Scioto Reserve Country Club

Scioto Reserve Country Club
Social & Pool-Only
Membership Application

Membership Information
Name:				Date of Birth:
Address:
City:		State:		Zip Code:
E-mail Address:
Residential Phone:			Cell Phone:
Marital Status:	Single Married

Spouse Information
Name:				Date of Birth:
Spouse E-mail:

Dependent Information

Name:				Date of Birth:
Name:				Date of Birth:
Name:				Date of Birth:
Name:				Date of Birth:
Name:				Date of Birth:

Membership Type

	Single	Family
Pool-Only:	Golf	Social

Acknowledgement of Terms


Please Initial I have read the term and conditions set forth in the Scioto Reserve Country Club Rules & Regulations and agree to the terms and conditions within.

                          Please Initial I understand that my terms of membership with Scioto Reserve Country Club shall begin with an initial term of 12 consecutive months after which it will continue on a month to month basis. I can resign at any time with a 90 day written notice after the initial 12 months.

                          Please Initial I understand the terms and conditions of all mandatory annual fees (Spending Minimums, Mill River Membership, Range Fees, Handicap Fees, and Tournament Fees) relative to my membership type. I also understand the terms and conditions of all optional fees (Locker Fees, Bag Storage Fees, and Social Golf Fees). Terms and conditions of the aforementioned fees and memberships are outlined in the Scioto Reserve Country Club Rules & Regulations.

Release of Liability
Please read before signing below

In consideration of any and all participation in Scioto Reserve Country Club, LLC programs, activities, and use of facilities and equipment, the undersigned (1) agrees and understands that the risk of serious and permanent injury from the activities in The Club does exist; (2) knowing and freely assumes all risks, both known and unknown, even if arising from the negligence of the Releasees or others, and assumes full responsibility for participation and use of the facilities; (3) willingly agrees to comply with the stated and customary terms and conditions for participation; (4) agrees that if any unusual or significant hazard is observed, activities will be discounted and such matter will be brought to the attention of the nearest official immediately; and (5) for myself and on behalf of my heirs, assigns, personal representatives, and next of kin, hereby releases and holds harmless the Scioto Reserve Country Club, LLC, its owners, officers, agents and/or employees, other participants, and, if applicable, owners and lessors of premises (Releasees), with respect to any and all injury, disability, death, or loss or damage to person or property, including vehicles parked on premises, whether arising from the negligence of the Releasees or otherwise, to the fullest extent permitted by law.

I have read this release of liability and assumption of risk agreement; fully understand its terms, fully understand that I have given up substantial rights by signing it, and sign it freely and voluntarily.

Members's Signature: Date: 2/4/2012

Spouse's Signature: Date: 2/4/2012

For Parents/Guardians of dependents under the age of 23 (under the age of 22 at time of registration)

This is to certify that I, as parent/guardian with legal responsibility for this dependent/participant, do consent and agree to his/her release, as provided above, of all the Releasees, and, for myself, my heirs, assigns, and next of kin, I release and agree to indemnify and hold harmless the Releasees from any and all liability incident to my dependents involvement or participation in these programs as provided above, even if arising from the Releasees negligence, to the fullest extent permitted by law.

Members's Signature: Date: 2/4/2012

Spouse's Signature: Date: 2/4/2012

Select One: Visa MastercardAMEXDiscover Checking Savings

Credit Card Number:

Expiration Date:

If you choose this option, you will need to come to Scioto Reserve Country Club and this information will be collected at the club.

Bank Name __________________________

Account Number ______________________

Routing Number ______________________

I would like to charge my entry fee into the club using the above credit card.

Initiation Fee:$ Monthly Dues (billed the 1^st of each month): $

Applicant Signature:

Date:

2/4/2012

Member Services Information
To be filled out by Member Services Representative of Scioto Reserve Country Club

Membership Number__________________

Member Password____________________

Salesperson’s Name:

Signature____________________________________________

Referring Member Name
(if applicable):

Initiation Fee $__________

First Month Prorate $__________

Golf Fees Prorate $__________

Subtotal $__________

Sales Tax $__________

Guest Passes $__________

Total Initial Payment $__________