Name: ____________________________________________________________________________ DOB: _________________________________________

Address:_______________________________________________________City: ___________________________________ ZIP: ____________________

Home Phone: _______________________________________________ Cell Phone: _____________________________________________________
Mothers Name: ________________________________________________________________ DOB: _________________________________________
Employer:____________________________________________________________________ Work Phone: ____________________________________
Email: ________________________________________________________________________
Fathers Name: _________________________________________________________________ DOB: _________________________________________
Employer: ___________________________________________________________________ Work Phone: ____________________________________
Email: ________________________________________________________________________
Please list whom to call in case of an emergency (when Mother or Father cannot be reached)
1)

Name:____________________________________________________ Relationship to Child: ____________________________________

Home Phone: ___________________________________________ Cell Phone: _________________________________________________

2)

Name:____________________________________________________ Relationship to Child: ____________________________________

Home Phone: ___________________________________________ Cell Phone: _________________________________________________

Please list any special interests or hobbies that your child may have: _____________________________________
_____________________________________________________________________________________________________________________________________
Can your child swim? (_____) Yes

(_____) No

(_____) Some

If Some, please explain: ____________________________________________________________________________________________________

Please list any allergies, medical conditions or handicapped conditions of your child: _______________
______________________________________________________________________________________________________________________________________
Please list any diet or activity restriction your child may have: ______________________________________________
______________________________________________________________________________________________________________________________________
Please list any medication that your child is currently taking:_________________________________________________
______________________________________________________________________________________________________________________________________
Will your child need to be given these medications during the time of 7:30 and 5:30? (____) Yes (____) No

(If yes, please make sure that you speak with the Camp Director about filling out a form)
- One time $25.00 Registration Fee must be paid at the time of registration Camper: (_____) Member ($55.00/wk)

(_____) Non-Member ($75.00/wk)

(_____) Scholarship (Varies)

Other Children registering for YMCA Summer Camp: Name:____________________________________________________________

Name:____________________________________________________________

(Sibling discount of $5.00 per child will be given for each week of YMCA Summer Camp and the Registration Fee.)

For 4 and 5 Year Olds Only

Your child must be potty trained, able to communicate and you must be able to provide an extra set of clothes daily.
Initial:______________________

Pick-up
The following person/people are authorized to pick-up the child.
Be prepared to show photo identification
Name:______________________________________________
Relation:___________________________________________

Name:______________________________________________
Relation:___________________________________________

Name:______________________________________________
Relation:___________________________________________

Name:______________________________________________
Relation:___________________________________________

(only people on this list will be authorized to pick-up the child. NO EXCEPTIONS! )

YMCA PROGRAM PARTICIPANT

RELEASE AND WAIVER OF LIABILITY AND INDEMNITY AGREEMENT
YMCA OF THE COOSA VALLEY
IN CONSIDERATION FOR PROGRAMS AND ACTIVITIES of the YMCA for any purpose, including, but not limited to observation or use of facilities or
equipment, or participation in any off-site program affiliated with the YMCA, the undersigned, for himself or herself and any personal representatives, heirs and
next of kin, hereby acknowledges, agrees and represents that he or she has, or immediately upon entering or participating ins pect and carefully consider such
premises and facilities or the affiliated program constitutes an acknowledge that such premises and all facilities and equipm ent thereon and such affiliated program
have been inspected and carefully considered and that the undersigned finds and accepts same an being safe and reasonably suited for the purpose of such
observation, use or participation.
IN FURTHER CONSIDERATION OF BEING PERMITTED TO ENTER THE YMCA FOR ANY PURPOSE INCLUDING, BUT NOT LIMITED TO
OBSERVATION OR USE OF FACILITIES OR EQUIPMENT, OR PARTICIPATION IN ANY OFF-SITE PROGRAM AFFILIATED WITH THE
YMCA, THE UNDERSIGNED HEREBY AGREES TO THE FOLLOWING:
THE UNDERSIGNED HEREBY RELEASES, WAIVES, DISCHARGES AND CONVENANTS NOT TO SUE the YMCA and all branches thereof, its
directors, officers, employees, and agents (hereinafter referred to as releasees) from all liability to the undersigned, his personal representatives, assigns, heir, and
next of kin for any loss or damages, and any claim or demands therefore on account of injury to the person or property or r esulting in death of the undersigned,
whether caused by negligence of the releasees or otherwise while the undersigned is in, upon, or about the premises or any facilities equipment therein or
participating in any program affiliated with the YMCA.
THE UNDERSIGNED HEREBY AGREES TO INDEMIFY AND SAVE AND HOLD HARMLESS the releasees and each of them from any loss, liability,
damage, or cost they may incur due to the presence of the undersigned in, upon, or about the YMCA premises or in any way observing or using any facilities or
equipment of the YMCA or participating in any program affiliated with the YMCA whether caused by the negligence of the releas ees or otherwise.
THE UNDERSIGNED HEREBY ASSUMES FULL RESPONSIBILTY FOR AND RISK OF BODILY INJURY, DEATH OR PROPERTY DAMAGE
due to negligence of the releasee or otherwise while in about or upon the premises of the YMCA and/or while using the premises or any facilities or equipment
thereon or participating in any program affiliated with the YMCA.
THE UNDESIGNED further expressly agrees that the foregoing RELEASE AND WAIVER AND LIABILTY AND INDEMITY AGREEMENT is intended to
be as broad and inclusive as is permitted by law of the State of Alabama and that if any portion thereof is held invalid, it is agreed that the balance shall, not
withstanding continue in full legal force and effect.
THE UNDERSIGNED HAS READ AND VOLUNTARILY SIGNS THE RELEASE AND WAIVER AND LIABILTY AND INDEMINTY
AGREEMENT, and further agrees that no oral representations, statements or inducement apart from the foregoing written agreement have b een made.
I HAVE READ AND UNDERSTAND THIS DOCUMENT AND RELEASE

Participants Name:______________________________________________
Parent/Guardian Name (PRINT):___________________________________
Parent/Guardian Signature:________________________________________
Date: _________________________________________________________