Youth - Program Registration - Ymca Of Northwest Florida
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1YMCA OF NORTHWEST FLORIDA
PROGRAM REGISTRATION
YOUTH
Participant Name __________________________________
Today’s Date _______________________
Date of Birth _________________
Age _______
Sex ________ Race ___________________
Parent’s Name _______________________________ Date of Birth ___________ Y Member? YES or NO
Complete Home Address _______________________________________________________________
Phone: Home _____________________
Work ____________________ Cell ____________________
Email address ________________________________________________________________________
Emergency Contact ___________________________________
Phone: ________________________
Program Registration for (circle one): Swim Lessons
Swim Team
Martial Arts
Dance
Cheerleading
Soccer
Flag Football
Volleyball
Basketball
Baseball/T-ball
Gymnastics
Other: ___________
Previous experience in this program: Have you participated before? ____ when? __________________
Shirt Size (if applicable for this program)
YXS
YS
YM
YL
AS
AM
AL
AXL
Any allergies? __________________________
Special needs? ________________________________
Volunteer: ___ Coach
____ Asst Coach
____ Referee
____ Team Parent
____ Help with phone calls
PHOTO AND VIDEO RELEASE
I give permission to the YMCA of Northwest Florida to use, without limitations or obligation, photographs, film footage, or
tape recordings which may include my child’s image or voice for purposes of promoting or interpreting Y programs. I
agree to abide by all program rules and will conduct myself in an appropriate manner during all program activities.
______________________________________
_________________________________________
Printed Name of Participant
Signature of Participant/Parent/Guardian
_________________
_________________________________________
Date
Class Name
Start Date of Class
In case of program cancellation, fees paid will be applied to a later date or refunded upon request.
The YMCA does NOT guarantee specific requests for coaches, teams, players or practice times.
FULL WAIVER ON REVERSE SIDE MUST BE SIGNED AND DATED
Home Branch: ______________ Staff Initials: _________________
YouthProgReg rev 10-1-13
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