Cameron Regional YMCA
PROGRAM REGISTRATION FORM
Name of Participant _______________________________ Mbr ______ Mbr ______ Sex ______
Birthdate _________/_________/_________ Age _______________ Height ________________
Address _____________________________________ City ____________________ State ________
Zip Code _______________
Email Address ___________________________________________
Phone ________________________School ___________________________
Session ______________________ Time ___________
Special Health Needs or Accommodations
Work or Cell Phone
In Emergency Contact ____________________________________________
Youth Sports Information:
1st Time Participant _______________
# of Previous Seasons as Participant ________________________
T-Shirt Size: Adult Sizes: AS
Youth Sizes: 6—8
______________________________ will be willing to participate in support of this program as a
Coach or Assistant Coach (circle one).
Coach’s Shirt Size: S
1. I hereby certify that my child is in normal health capable of safe participation in YMCA programs. I assume
all risk(s) and hazards incidental to the conduct of this program and for the transportation to and from the
program. I hereby authorize the YMCA to obtain medical treatment for my child in the event that
parent(s) and the emergency contact cannot be reached.
2. I support the YMCA Philosophy, which is based on participation, fun, physical fitness and health, skill
development, team work, fair play, family involvement, and volunteer leadership.
3. I ___ do
___ do not authorize the YMCA to take and use photographs, slides or videotapes of my child
as may be needed for publication and promotional purposes.
FOR OFFICE USE
Amount Paid ________ Check _____ Cash _____ Receipt#________________