2012 Membership Rates and Registration Form

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Mail-In Registration Form – 2012 Membership

Last Name: ________________________ First Name: ________________________

Email Address: _____________________ Phone #: __________________________

Mailing Address: ______________________________________________________

Please select the type of membership:

_____ Family Membership _____ 1 Senior Membership

_____ Babysitter Add-On _____ 2 Senior Memberships

_____ Individual Membership _____ 10 pack Guest Passes

Please make checks payable to “Philipps Swim Club” or if using credit card:

Credit Card # ____________________ Exp Date: _____

Total Amount Enclosed $_________ Referred by: _________________________

Mail to: Philipps Swim Club, PO Box 58054 Cincinnati, Ohio 45258-0054