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Membership Application Form

I am interested in being invited for membership in the Costa Palmas community and desire to purchase a Family Membership in the Beach & Yacht Club Yacht Club and for purposes of considering my application, I am providing the following information to the Club:

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

Email

Relationship to the Member

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

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

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

Telephone

Name

Years Known

Address

Telephone

Upon signing this Application for Membership Form, I authorize and consent the disclosure and release of the information provided by me herein and the information requested by the Club for investigating my qualifications for membership, 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 Application for Membership Form to furnish all information requested by the Club and agree to hold the Club harmless from any and all such act.

I acknowledge that membership in the Club is by invitation only and that in order to acquire a membership in the Club, I must be invited for membership. I further acknowledge that Membership is contingent upon approval by the Club, which approval 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 the selected membership plan as well as all applicable Club rules and regulations.

NOTE: If the person completing this Application for Membership Form is married, the signature of both spouses is required

Dated

Applicant’s Name

Dated

Spouse’s Name