Campus Club Membership Form

Please complete and submit the form. Leave blank any fields that do not apply to you. You will receive a confirmation email when we have processed your application. If you have any questions, please call Ann Holt, Executive Director at 612-624-6626.

First name: *

Last name: *

Date of birth: *

Home address: *

City: *

State / Province / Region: *

Postal / Zip code: *

Best Email address : *

Best non-work phone number ( + area code): *

Referred By:

Let us know your affiliation to the University of Minnesota!
*Students are eligible for a special $50 membership. Club members at this level may not carry balances on their accounts and may not reserve rooms.
**UMAA Members that become a Campus Club Member receive 2 free months of membership to the Campus Club.

UMN Departments can apply for membership by clicking here.

Affiliation: *

College and Department: *

Choose your level of support!
Your membership let's the Campus Club continue our mission to bring people together and supports our unique programs.

Basic | $88 /year - Receive a free lunch when you join

Payment Options: $88 yearly OR $7.33 monthly OR by payroll deduction (UMN EMPLOYEES ONLY).
Payroll Options: 12 month deduction for $3.38/check OR 10 month deduction for $4.19/check OR 9 month deduction for $4.63/check.

Friend of the Club | $260 /year - Receive a free lunch when you join plus a $50 annual credit

Payment Options: $260 yearly OR $21.67 monthly OR by payroll deduction (UMN EMPLOYEES ONLY).
Payroll Options: 12 month deduction for $10.00/check OR 10 month deduction for $12.38/check OR 9 month deduction for $13.68/check.

Advocate | $650 /year - Receive a free lunch when you join plus a $100 annual credit

Payment Options: $650 yearly OR $54.17 monthly OR by payroll deduction (UMN EMPLOYEES ONLY).
Payroll Options: 12 month deduction for $25.00/check OR 10 month deduction for $30.95/check OR 9 month deduction for $34.21/check.

Leader | $1300 /year - Receive a free lunch when you join plus a $200 annual credit

Payment Options: $1300 yearly OR $108.33 monthly OR by payroll deduction (UMN EMPLOYEES ONLY).
Payroll Options: 12 month deduction for $50.00/check OR 10 month deduction for $61.90/check OR 9 month deduction for $68.42/check.

Student | $50 /year - Receive a free lunch when you join. Cannot carry an account balance or reserve rooms.

Payment Option: $50 yearly (UMN STUDENTS ONLY).

Choose how you pay!
You may pay yearly via credit card or check.
Payroll deduction is a billing option for University employees only.
It is available in three options - 12 month, 10 month, and 9 month. By choosing this option you are agreeing to continue your membership until you advise the Club otherwise.

Dues payments: *

	By payroll deduction
	Monthly
	Yearly

Payment method: *

Credit card option. Call 612-626-1510 or charge at the Club.

University ID

University ID # - Required for payroll deduction:

Payroll Deduction:

	10 month appointment
	12 month appointment
	9 month appointment

Please make a second card for my spouse/partner ( no extra charge ):

I hereby apply for membership in The Campus Club. I agree to pay the dues and charges I incur. I understand that all charges for Club services are due within 30 days. I certify that I have read the Personal Membership Polices and accept its terms. *

Today's date: *

Submit

	1) Basic \| $88/year
	2) Friend of the Club \| $260/year
	3) Advocate \| $650/year
	4) Leader \| $1300/year
	5) Student Special* \| $50/year

Campus Club Membership Form

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