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Membership Form

As a current member of the Costa Palmas community holding a Family Membership in the Beach & Yacht Club, I am providing the following family information so that it may be reviewed and added to my membership profile. The information provided below pertains to my designated family members under the:

Select:

Beach & Yacht Club

Yacht Club

Personal

Name

D.O.B.

Mailing Address

Email

Phone Number

T-shirt Size

Billing Address (if different from Mailing Address)

Marital Status

Single

Married

Partner

Anniversary Date

Spouse / Partner

D.O.B.

Spouse / Partner Email Address

Phone Number

T-shirt Size

Billing Contact

Relationship to the Member

Email

Immediate Family Members

As defined by our policy, this includes unmarried children under the age of 25, living at home or attending school on a full-time basis.

Name

D.O.B.

Email

Relationship to Primary Member

Name

D.O.B.

Email

Relationship to Primary Member

Name

D.O.B.

Email

Relationship to Primary Member

Name

D.O.B.

Email

Relationship to Primary Member

Name

D.O.B.

Email

Relationship to Primary Member

Extended Family Members

As defined by our policy, this includes - the parents of the primary member(s).

Name

D.O.B.

Email

Relationship to Primary Member

Name

D.O.B.

Email

Relationship to Primary Member

Name

D.O.B.

Email

Relationship to Primary Member

Name

D.O.B.

Email

Relationship to Primary Member

Extended Family Members

As defined by our policy, this includes - children over the age of 25 & married children, along with their respective spouses and their children (grandchildren of the primary member).

Name

D.O.B.

Email

Relationship to Primary Member

Name

D.O.B.

Email

Relationship to Primary Member

Name

D.O.B.

Email

Relationship to Primary Member

Name

D.O.B.

Email

Relationship to Primary Member

Name

D.O.B.

Email

Relationship to Primary Member

Name

D.O.B.

Email

Relationship to Primary Member

Name

D.O.B.

Email

Relationship to Primary Member

Name

D.O.B.

Email

Relationship to Primary Member

Food Allergies and/or Dietary Preferences

Special Requests

Business

Company Name

Title

Business Address

Years at the Company

Retired

Company Name

Title

Business Address

Years at the Company

Retired

Member or Family References

Name

Years Known

Address

Phone Nnumber

Name

Years Known

Address

Phone Nnumber

Upon signing this Family Membership Information Form, I authorize and consent to the disclosure and release of the information provided by me herein and any information requested by the Club for the purpose of verifying the family members listed on my membership profile, including, without limitation, law enforcement records and credit history, and shall hold the Club harmless from any and all such acts. I further authorize those persons or entities set forth in this Form to furnish all information requested by the Club and agree to hold the Club harmless from any and all such acts.

I acknowledge that membership in the Club is by invitation only and that adding family members to my membership profile is contingent upon the Club's approval, which shall be at its sole and exclusive discretion.

I understand that all names listed are subject to final approval by the Club and must comply with the terms of my selected membership plan as well as all applicable Club rules and regulations.

NOTE: If the member completing this Family Membership Information Form is married, the signature of both spouses is required.

Dated

Applicant’s Name

Dated

Spouse’s Name