University Recreation

Part-time Instructor Membership Form

Annual SRC Membership (Valid for one year from date of activation)

$270 (you only pay taxes)

Important tax information
By submitting the form below, I hereby authorize the payroll department to deduct taxes from my paycheck. I understand this agreement is non-revocable and cannot be refunded for any reason. I understand that $270 will be reported as extra income, and I will be taxed on this amount.

Membership type (required)

Name (First and Last) (required)

Last four digits of WIN (required)

Home address

City

State

ZIP code

Home/cellphone

Work phone

Email address (required)

University department (required)

Pay cycle

Pay cycle as defined by payroll and how often you receive your paycheck (biweekly or semimonthly)

Agree to membership contract (required)

Student Recreation Center membership contract (printable pdf)

Enroll in auto renewal?

Please indicate if you would like your membership to auto-renewed each year. Auto renewal is subject to verification of continued eligibility through PIO contract.