DOD ARMED SERVICES YMCA INITIATIVE MILITARY OUTREACH INITIATIVE MEMBERSHIP APPLICATION INSTRUCTIONS: See "Program Instructions and Requirements" for additional information. Service Member/Spouse complete all sections and email signed form to the appropriate MCAO org box. NOTE: Renewal applications must include the facility attendance report and if applicable, a waiver request for non-compliance. Waived COVID-19. Section 1 Status (Select ALL That Apply): NEW Request RENEWAL Request Waiver Request Facility (Select One): YMCA Facility Private Fitness Facility Fitness Facility Name: ______________________________________________________________________ Street Address: ___________________________________________________________________________ (Category 1 must list their "unit-designated" fitness facility listed on the MCAO approved "Designation Form") Section 2 Service (Select ALL That Apply): National Guard Reserve Army Navy Marine Corps Air Force Assignment Timeline (mm/yyyy) Start: ______________________________ End: _____________________________ Title 10 Category (Select One Category 1 must complete unit information) Category 1 Active Duty Independent Duty Personnel Unit Name: _____________________________________ Unit Phone: _______________________ Unit POC: _______________________________________ POC Email: ________________________ Duty Station Street Address: __________________________________________________________ Category 2 Unaccompanied Spouse/Family of Active Duty Category 3 Unaccompanied Spouse/Family of Deployed Guard and Reserves Category 4 Community Based Warrior Transition Unit / Warrior Care Unit Section 3 Membership Type (Select One): Service Member ONLY Spouse ONLY Family (2+) Service Member (Last, First): _________________________________________________________ Rank: _________ Duty Email: __________________________________________________ Duty Phone: _______________________ (List ONLY dependents that will use the facility; use additional sheet if necessary) Spouse (Last, First): _______________________________________________________________________________ Child 1: _____________________________ Age: ______ Child 4: ____________________________ Age: ______ Child 2: _____________________________ Age: ______ Child 5: ____________________________ Age: ______ Child 3: _____________________________ Age: ______ Child 6: ____________________________ Age: ______ Member Certification: I certify the information provided is accurate and all eligibility criteria for the specified category is met (including Title 10 requirement). I agree to pay any cost above the DoD-funded rate ($50 single / $70 family) to include any optional services I elect. I understand that I must comply with the mandatory attendance requirement to be eligible for renewal consideration and that intentionally providing false information to secure services under a Defense contract is cause for disciplinary action and may be prosecutable. Service Member/Spouse Signature: ________________________________________ Date: __________________ MCAO Verification (Select One): NEW Approved (or) RENEWAL Request for ASYMCA Determination Digital Signature/Date: ___________________________________________________________________________ This form contains FOR OFFICIAL USE ONLY information which must be protected under the Freedom of Information Act (5 U.S.C. 552) and/or the Privacy Act of 1974 (5 U.S.C. 552a). Unauthorized disclosure or misuse of PERSONAL INFORMATION may result in disciplinary action, criminal and/or civil penalties. Further distribution is prohibited without the approval of the author unless the recipient has a need to know in the performance of official duties. If you have received this in error, please notify the sender and delete all copies. 06/18/2020 - 1400Adobe PDF Library 20.9.95