Laurelhurst Recreation, Inc. ~ Cabana Club
1063 Colony Hills Lane ~ Cupertino, CA 95014 ~ (408) 725-9389 ~ FAX (408) 252-8938
 2010 MEMBERSHIP APPLICATION 
MID-SEASON PRORATED MEMBERSHIP
FOR A PRINTABLE VERSION (ADOBE ACROBAT) OF THIS FORM, CLICK HERE.

DATE:_____________________                               
                                     
FAMILY NAME:_________________________________________   PHONE: _____________________

ADDRESS:_____________________________________________________  OWN____      RENT____

CITY:______________________________ ZIP:_______________ YEARS AT THIS ADDRESS:_______

E-MAIL: _______________________________________________

FAMILY MEMBERS:  
(PLEASE INDICATE WITH A "Y or N"  THOSE CHILDREN WHO CAN and CANNOT SWIM - LESSONS MAY BE AVAILABLE).
ADULTS (first names) : _______________________________    __________________________________

OTHERS RESIDING WITH FAMILY: ________________________________________________________

PLEASE PROVIDE THE FOLLOWING ADDITIONAL INFORMATION:
OCCUPATION(S):

HUSBAND's:________________________________EMPLOYER:__________________________________________
WORK PHONE:_____________________________
WIFE's:____________________________________ EMPLOYER:__________________________________________
WORK PHONE:_____________________________

SPECIAL NEEDS OR CONDITIONS OF ANY FAMILY MEMBERS:___________________________________________

OTHER EMERGENCY PHONE CONTACT (IMPORTANT!) Name:_______________Phone:_______________________
WE WILL PROBABLY      __WALK,    __BICYCLE,   __DRIVE   TO THE POOL.  
VEHICLE INFO: MAKE:____________MODEL:___________  COLOR: _________VEH. LIC. NO.:_________________

Please return this completed form (all lines must be filled in, or your application is invalid) along with your PRORATED membership dues ($375) to Laurelhurst Recreation Inc. (LRI), at the address above. Membership is limited. Your membership is subject to board approval.

I AGREE TO ABIDE BY ALL LRI RULES, POLICIES, and PROCEDURES (POSTED AT POOL)

X____________________________________________                      _______________________________________
                                  (SIGNATURE)                                                                              RECOMMENDED BY (optional):

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© 2010, Laurelhurst Recreation, Inc.
Hours and fees subject to change.