Dartmouth Club Application

Personal Information

Name:

Date of Birth:

Prefix:

Email:

Phone:

Home Address:

Business Address:

Send Statements By:

Both

How did you hear about the Dartmouth Club at The Yale Club?

School Information

Please list all colleges and universities from which you have received a degree.

School:

Degree:

Year of Graduation:

School:

Degree:

Year of Graduation:

School:

Degree:

Year of Graduation:

School:

Degree:

Year of Graduation:

School:

Degree:

Year of Graduation:

Extracurricular Activities at Dartmouth:

Spouse/Domestic Partner Information

Please fill in your spouse/domestic partner’s information if you would like them to have signing privileges. There is a $190.53 annual charge (March 1 – February 28) for the signing privilege. This fee is not prorated. This signing privilege allows your spouse/domestic partner to get their own account number and use the Club without the primary member being present. Only one signing privilege account is allowed per primary account.

I would like signing privileges for my spouse/domestic partner. I will be responsible for all charges incurred by person authorized to sign.

Name:

Date of Birth:

Prefix:

Email Address:

Graduation Year:

Athletic Package Information

Sign here if you would like to add the Athletic Package to your membership. The Athletic Package is $560 annually ($140 for 2015 undergraduates, $280 for 2014 undergraduates, and $420 for 2013 undergrad graduates). You must opt-into the Athletic Package in order to have it. Please note the $560 fee does not include tax.

I would like to sign up for the Athletic Package:

Yes

Signature:

Date:

Clubhouse Membership is available to all Dartmouth degree holders, faculty, and full-time graduate students. Graduate students must submit verification, either a copy of one’s course schedule or most recent tuition statement, with application. PDF format is preferable.

We ask that you allow one week for processing.

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