Birmingham Next Membership Registration

Membership Type

How did you hear about Birmingham Next?

Master Member

First Name

Last Name

Street Address

Street Address 2

City

State ALAKAZARCACOCTDEDCFLGAHIIDILINIAKSKYLAMEMDMAMIMNMSMOMTNENVNHNJNMNYNCNDOHOKORPARISCSDTNTXUTVTVAWAWVWIWY

Zip

Birthdate

Gender

Email

Phone

Emergency Contact Name

Emergency Contact Phone

Relationship

Medical Concerns

Second Member

Provide this information if it is different then MASTER MEMBER

First Name

Last Name

Birthdate

Gender

Email

Phone

Second Member Emergency Contact Information

Name

Phone

Relationship

Other Member Information

Information Below is for Next use only and will not be shared.

Member Lives Alone?

Preferences

I am interested volunteering in:

Ethnic Background

Releases

In consideration of being enrolled in any Next program, I hereby assume all risks in connection with such program, and I further release Next, the instructors, and/or agents/operators of such programs for any injury or damage that may befall me while participating in such programs, including all risks connected therewith, whether foreseen or unforeseen; and I further agree to save and hold harmless Next, the program and persons from any and all claims by me, my family, estate, heirs or assigns, arising out of my enrollment and participation in such programs.

Membership Participation Policy: By becoming a member of Next, I (we) agree to the policies pertaining to Member Participation found on our website. If you would like a printed copy, please let us know.

I hereby release to Next any and all rights to my image likeness (photographic and/or videotape), and the sounds of my voice as record on videotape if taken while I am at the Next center or while participating in a Next program, trip or other type of function not at the Next center. I give permission to Next to reuse all of my appearances on such photographic or videotaping by Next, its agents, and contractors. I further agree to release, discharge and save harmless Next, including its representatives or designees, from any legal proceedings that may arise in relation to the conditions of the above paragraph.