Athletic Center Membership Application
Welcome to secure online registration for membership at QCC Athletic Center. Before you register, please review the following policies:
  • All children under age 10 must be accompanied by an adult
  • All year memberships are valid 12 months from start date
  • Applicant is responsible for all add on members on the application
  • Applicant agrees to follow all policies and rules of the Athletic Center and QCC
  • Failure to follow policies and rules will result in suspension of membership privileges
Membership Plan
Applicant Information
First Name
Last Name
Address
City
State
ZIP Code
Home Phone
(xxx-xxx-xxxx)
Cell Phone (optional)
(xxx-xxx-xxxx)
Email
Re-enter Email
Additional Members
If you selected a family membership, please provide the name and date of birth information for :your spouse and children.
1.
DOB
2.
DOB
3.
DOB
4.
DOB
5.
DOB
Emergency Contact
Contact Name
Contact Phone
(xxx-xxx-xxxx)

I certify that the above information is complete and accurate to the best of my knowledge. I have read and understand all information on the Application and Hold Harmless Waiver. I also understand that falsifying information can result in my membership being revoked.

I agree