Example Form - Miami Valley Golf

Our Partners

Online Membership Application Form

I wish to join the following club/cluster:

I wish to join under the following membership category:

Add a Performance Center Membership to my Canongate Membership: Single ($25 / month) Family ($40 / month)

Annual Range Program Billing Option
All Canongate Golf Clubs Associate and Full Golf Members are enrolled in the annual driving range program. The program includes unlimited range balls at all Canongate locations for you and anyone included on your membership. Please indicate if you would like to be billed annually or quarterly. A non-response will result in an annual billing cycle. You do not need to submit payment for the range program when joining. The range charge will appear on your billing statement and will be charged on your first statement if you choose the annual payment option and to the start of the next quarter if you choose the quarterly payment option.

I wish to have my Range Program billed:

I submit the following information for confidential consideration for membership:
Social Security #:		Driver's License #:
Name:			Birthdate:
Spouse's Name:			Birthdate:
Children:	Sex:		Birthdate:
	Sex:		Birthdate:
	Sex:		Birthdate:
Home Address:
City:	State:		Zip Code:
Home Phone:		Cell Phone:
E-mail Address:		Spouse E-mail:
Billing Address: (if different)
City:	State:		Zip Code:
Employed By:
Position:	Business Phone:

EZ-Pay Enrollment
All new members have the option to utilize EZ-Pay for the first 90 days of membership. This system allows you to automatically pay your dues and charges with your credit card or checking account. This system is worry free as you will always receive a detailed statement via mail and email prior to your credit card or checking account being charged. To enroll in EZ-Pay via credit card, simply enter your credit card information below. If you prefer EZ-Pay via checking account, please ask your Membership Director or Office Manager for a checking account enrollment form. You can discontinue EZ-Pay by contacting the club business office. If you are not using EZ-Pay in the future, the club reserves the right to charge your credit card any time your account becomes more than 60 days past due.

Credit Card Type:	Visa Mastercard AMEX Discover
Credit Card Number:		Expiration Date:	/
I would like to charge my entry fee into the club using the above credit card.		Amount to Charge:

I agree to be responsible for the charges incurred by myself or my family. I agree to abide by all rules and regulations now in effect at the club and any amendments thereto which may be made from time to time. I agree to remain a member for at least one year after which time I can resign by providing the club with 30 days written notice. I understand that I am responsible for all dues and applicable fees during the 30 day notice period. If I should resign before one year, I agree to pay a $300 cancellation fee. Upon signing this application, I authorize the disclosure and release of information requested by the Club for investigating my qualifications for membership, including without limitation, my credit history.

Signature:

Date:

6/8/2026

Please complete the Canongate New Member Profile below. Thank you.

1. What is your proximity to the club?
Less than 5 miles
5 - 10 miles
10 - 20 miles
More than 20 miles

5. Do you have friends of family who are members of any Canongate Golf Club?
No
Yes

2. What is your age?
18-24
25-34
35-44
45-54
55-64
65 and over

6. Have you previously been a member of any Canongate Golf Club?
No Yes	If yes, how long ago did you leave? Less than 1 year 1 to 2 years 2 to 3 years 3 to 4 years More than 4 years

3. Who in your household will be utilizing your club membership?
Check all that apply.
You
Spouse
Children or other dependents

7. How do you plan to use the club?
Check all that apply.
Golf
Social
Dining
Entertain Business Contacts

4. What is the approximate value of your home?
(All information provided is confidential)
$150,000 - $199,999
$200,000 - $249,999
$250,000 - $299,999
$300,000 - $349,999
$350,000 - $399,999
$400,000 - $449,999
$450,000 - $499,999
Over $500,000

8. Have you visited the club website?
No
Yes

9. In what media have you seen or heard the clubs advertised? Check all that apply.
Newspaper Magazine Radio	Television Mailing None

10. Would you or anyone in your family like more information about the following? Check all that apply. A staff member or association leader will contact you via phone or email with additional information.
Adult Golf Lessons Junior Golf Lessons Custom Golf Club Fitting Getting a USGA Handicap	Men's Golf Association* Ladies Golf Association* Couples Golf Association* Singles Golf Association* Seniors Golf Association*	Adult Tennis Junior Tennis Adult Social Programs Family Programming
* Associations vary by club/cluster. Not all are available at each club/cluster. ** Where available.

11. Do you have any friends or family you would like to refer to the club? If so, please complete:
Name:	Phone:	E-mail Address:

Please validate your entry and type the word in the image below: