First Name *

Middle Initial

Last Name *

Birth Date *

Father's Name

Mother's Name

Sibling Name

Sibling Name

Street Address *

City *

State *

Zip Code *

Home Phone *

Work Phone

Cell Phone

Email Address *

US Squash #

Montly Dues Option: Select this option and you will have 12 monthly payments billed to your Visa, MC, AmX or Discover card. Dues are $39.95 plus tax ($2.80) for a total monthly charge of $42.75. The Initiation Fee of $150 is added to your 1st monthly statement or can be billed in 3 monthly payments of $50 - please email your preference to charlie@cjsquash.com (waived on renewals).

Monthly Option

Credit Card Type Select From List Below MasterCard Visa American Express Discover

Credit Card #:

Expiration Date

Security Code

Initiation Fee Option (If applicable) Bill in Full with 1st Month Bill in 3 $50 Installments

I authorize the Dayton Squash Center to charge my credit card the 12 Monthly payments of $42.75 (and the $150 Inititiation Fee if applicable) in return for my annual membership in the club. I understand that my membership s for one full year and that I am responsible for all 12 payments. If membership is terminated prior to 12 months of use, I agree that my credit card shall be charged the remaining balance. (Select below to authorize charges)

Authorize Charge

Automatic Renewal of Monthly Option: Check this box and your membership will renew automatically on your 12 month anniversary unless you notify us in writing.

Automatic Renewal

Annual Dues Option: Select this option to pay your entire annual dues by check and receive a 15% discount!

Check for $448.75 (New Members, include $150 Initiation Fee for a total of $598.75) must be received within 7 days of agreement submission.

Mail Check To:
Dayton Squash Center
3200 West Tech Rd.
Miamisburg, OH 45342
Attn. Membership

Annual Option