Intramural/Recreation User Application

Intramural/Recreation User Application
Applications must be renewed each year, prior to Sept. 1. An official NCCC ID Card is required to use Intramural / Recreation facilities.

Before you can participate in any intramural and recreation activity, ALL contents of this application must be read, completed, and submitted online.
Your Status:*

StudentFacultyStaffAdministrationAlumni
Full Name:*

First NameMiddle NameLast Name
Birth Date:*

MonthDayYear
Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Home Phone:*

Area CodePhone Number
Work Phone:

Area CodePhone Number
E-mail:*
Emergency Contact:*
Emergency Contact Phone:*

Area CodePhone Number
Relationship to you:

Facility Use
I have read the "Policies and Procedures" document and I fully understand its contents. I agree to keep and obey all policies and procedures regarding the use of NCCC recreation and intramural facilities, as well as any additional or updated policies and procedures that may arise. *

YesNo
I have read the "Agreement for Facility Use" document and I fully understand its contents. I agree to comply with all the rules and conditions outlined therein and to keep and obey all policies and procedures regarding the use of NCCC recreation and intramural facilities, as well as any additional or updated policies and procedures that may arise. *

YesNo

Verification
I verify that I have answered all questions to my full satisfaction and that I have read the required documents and understand the information, policies, and procedures outlined in them. *

YesNo
In lieu of a signature, we require a unique identifier. Please select the month in which you were born:*
Questions?
Contact the NCCC Fitness Center at: 716-614-6746.
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