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LSSE Aquatic Center Membership Registration Form

 

70 Boltwood Walk      (413) 259-3065

Office Hours: 8:00 a.m.-4:30 p.m.    Monday through Friday

 

Household Information

 

Primary Head of Household:    

(Please enter First and Last Names)
Home Phone:       Work Phone:  Cell Phone:
Mailing Address:  
Town:     

State:    Zip:

Residential Address:  
Town:      

State:   Zip:

Email Address:
Emergency Contact Name:      Emergency Phone: 

 

 
  Please check one category that describes each family member.
Family Members:
(must reside at the same address)		 Adult Child Senior Teen College Student
1.

2.

3.

4.

5.

6.

Membership Type
Please check one from each column

Full Year     

Family (2+)

Amherst Resident

1 Month Adult

School District Resident

 

 

 Senior Non-Resident
 

 

 Teen (13-18)

 

 
    College Student     

   

For membership prices click here.
 

Fee
Payment may be made by Visa, Mastercard or Discover only:
Card #:       Exp. Date:    Card Holder

Once you have completed the information on this form, please press the submit order button above once.  Enrollments will be processed by our staff according to order received.  
Please wait until you see a confirmation screen.  Thank you.