First Name: Last Name: Employee Number: Email: Phone ... - Guelph
www.gryphons.ca
Deadline for Winter Payroll Deduction Registration is: Friday, January 3rd, 2014 (NO DEDUCTION REQUESTS CAN BE GRANTED AFTER THIS DATE) PAYROLL DEDUCTION WINTER 2014 MEMBERSHIP FORM Pricing as of August 1, 2013 Please complete ALL the requested information and fax to 519-821-7973 attn: Adam Bailey.
First Name: Last Name: Subsidized Employees:(please check which group you belong to) _ CARG
_ CUPE 1334
_ EXEMPT
_ UGFA
_ USW 4120
_ ONA
_ CEP
_ P&M or PSA
_ UPA
_ UGFSEA
____OSSTF
_ EXEC & EXEC FAC
Employee Number: Email: Check all that apply:
Phone Number/Extension:
Membership Type *Taxes included* Subsidized Athletic Base Non-Subsidized Athletic Base Fitness Centre (includes Weight Room & Cardio Room) Fitness Class (includes Fitness Classes) FitPak (includes both Fitness Centre & Fitness Classes) ½ Locker 2/3 Locker (Available in Men’s Changeroom) Full Locker Towel Membership Number of Deductions per Semester
One Semester
# of Semesters
$101.87 $279.17 $39.00 $63.00 $85.00 $52.00 $65.00 $75.00 $39.00
7 **PLEASE NOTE THAT LOCKER MEMBERSHIP CANNOT BE GUARANTEED. THEY WILL DEPEND ON AVAILABILITY AT THE TIME OF MEMBERSHIP INPUT** Date Signature (The above signature indicates approval by payroll deduction for the indicated request) Waiver & Etiquette I hereby declare that I understand and agree to abide by the rules and any other regulations posted in the facility and or as directed by any Athletics staff member. I declare that I have sufficient skill, knowledge, and experience to safely make use of the equipment and facilities at the University of Guelph Athletics Centre. I recognize that the activity is potentially hazardous and could result in personal injury with potential impairments of future personal or professional life. I acknowledge and accept the responsibility for encouraging all participants to use the equipment in a safe responsible manner. PROTECTION OF PRIVACY We care about your privacy. Personal information that you provide to the University is collected under the authority of the University of Guelph Act (1964, sections 11 & 13). It is collected for the purpose of the Department of Athletics and will be protected at all times. If you have questions about the use and disclosure of this information call the Department of Athletics.
Deadline for Winter Payroll Deduction Registration is: Friday, January 3rd, 2014 (NO DEDUCTION REQUESTS CAN BE GRANTED AFTER THIS DATE) PAYROLL DEDUCTION WINTER 2014 MEMBERSHIP FORM Pricing as of August 1, 2013 Please complete ALL the requested information and fax to 519-821-7973 attn: Adam Bailey.
First Name: Last Name: Subsidized Employees:(please check which group you belong to) _ CARG
_ CUPE 1334
_ EXEMPT
_ UGFA
_ USW 4120
_ ONA
_ CEP
_ P&M or PSA
_ UPA
_ UGFSEA
____OSSTF
_ EXEC & EXEC FAC
Employee Number: Email: Check all that apply:
Phone Number/Extension:
Membership Type *Taxes included* Subsidized Athletic Base Non-Subsidized Athletic Base Fitness Centre (includes Weight Room & Cardio Room) Fitness Class (includes Fitness Classes) FitPak (includes both Fitness Centre & Fitness Classes) ½ Locker 2/3 Locker (Available in Men’s Changeroom) Full Locker Towel Membership Number of Deductions per Semester
One Semester
# of Semesters
$101.87 $279.17 $39.00 $63.00 $85.00 $52.00 $65.00 $75.00 $39.00
7 **PLEASE NOTE THAT LOCKER MEMBERSHIP CANNOT BE GUARANTEED. THEY WILL DEPEND ON AVAILABILITY AT THE TIME OF MEMBERSHIP INPUT** Date Signature (The above signature indicates approval by payroll deduction for the indicated request) Waiver & Etiquette I hereby declare that I understand and agree to abide by the rules and any other regulations posted in the facility and or as directed by any Athletics staff member. I declare that I have sufficient skill, knowledge, and experience to safely make use of the equipment and facilities at the University of Guelph Athletics Centre. I recognize that the activity is potentially hazardous and could result in personal injury with potential impairments of future personal or professional life. I acknowledge and accept the responsibility for encouraging all participants to use the equipment in a safe responsible manner. PROTECTION OF PRIVACY We care about your privacy. Personal information that you provide to the University is collected under the authority of the University of Guelph Act (1964, sections 11 & 13). It is collected for the purpose of the Department of Athletics and will be protected at all times. If you have questions about the use and disclosure of this information call the Department of Athletics.
