Program Registration Form - Cameron Regional Ymca

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Cameron Regional YMCA
PROGRAM REGISTRATION FORM
Facility
Non
Name of Participant _______________________________ Mbr ______ Mbr ______ Sex ______
Birthdate _________/_________/_________ Age _______________ Height ________________
Address _____________________________________ City ____________________ State ________
Zip Code _______________
Email Address ___________________________________________
Phone ________________________School ___________________________
Grade ___________
Program _________________________
Session ______________________ Time ___________
Special Health Needs or Accommodations
____________________________________________________
Parent
or _______________________________________________________
__________________________
Guardian
(Last)
(First)
Work or Cell Phone
In Emergency Contact ____________________________________________
Phone ___________________
Youth Sports Information:
1st Time Participant _______________
# of Previous Seasons as Participant ________________________
T-Shirt Size: Adult Sizes: AS
AM
AL
AXL
Youth Sizes: 6—8
10—12
14—16
______________________________ will be willing to participate in support of this program as a
(Name)
Coach or Assistant Coach (circle one).
Coach’s Shirt Size: S
M
L
XL
XXL
XXXL
AGREEMENT
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.
___________________________________________________
_________________________
Signature
Date
____________________________________________________________________________
________
FOR OFFICE USE
Date _________
Amount Paid ________ Check _____ Cash _____ Receipt#________________
Notes:

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