Hamden/north Haven Ymca Typhoon Swim Team Registration Form printable pdf download

HAMDEN/NORTH HAVEN YMCA

Typhoon Swim Team Registration Form

Participant’s First Name

Last

Boy_____ Girl

Address

City

State _______ Zip

Date of Birth _____________________ Age entering program._________ mos.________ Grade entering in Sept._______ Child lives with

Parent # 1

Parent # 2

Home Address

Home address

Please Check Which Phone Number You Would Like Used As Primary Contact Number

Home Phone # (

)

Home Phone #

(

)

Cell Phone #

(

)

Cell Phone #

(

Work Phone #

(

)

Work Phone #

(

)

E-Mail Address

(Weekly communications will be emailed to the e-mail addresses provided.

If a parent cannot be reached, give name and relationship of person to be called in case of emergency.

Name:

Relationship:

Home # (

)

Work # (

)

Cell # (

)

Does your child require special accommodations (social, behavioral, medicine)? No_______ Yes _____________

Parent/Guardian Permission:

I hereby give permission for my child to participate in all activities that are part of the program. I understand there are risks associated with

activities and programs in which my child is a participant. I hold the Y Branch, the Central Connecticut Coast YMCA, its employees, representatives,

agents, and assigns from any and all claims whatsoever against said parties resulting from or caused by my child’s participation. I grant permission to

have my child transported to one the YMCA's other facilities in case of inclement weather. I also grant permission for any pictures taken of my child

while in the program to be used for publicity and promotional purposes.

Guardian Authorization:

In order to ensure the well-being of all our participants and our ability to help you with picking up your child, please include every person that could

assume the custody of your child for any unforeseen circumstances. The YMCA WILL require photo I.D. to release any child to an authorized pick up

person listed on this form. I authorize the YMCA to release my child to the custody of the following people other than me:

________________________________________________________________________________________________ Relationship

Name:

______________________________________________________________________________________ Relationship

Name:

______________________________________________________________________________________ Relationship

The YMCA is required to permit either parent to pick up the child unless the YMCA is furnished with a copy of a court order to the contrary. Please

list below any persons not authorized to pick-up this participant and attach a copy of the court order.

Name:

______________________________________________________________________________________ Relationship

Name:

______________________________________________________________________________________ Relationship

I understand that the Central Connecticut Coast Young Men’s Christian Association, Inc. (the “Parent Company”) and all of its branches are a

charitable organization that makes its programs and facilities available to persons only on the condition that they agree to assume full responsibility

for injury and damage. Therefore in exchange for acceptance of the child in the YMCA programs, I release, on behalf of the child, myself and members

of the child’s family, the YMCA, the Parent Company, and officers, directors, employees and volunteers from all claims of damage or loss to the child’s

property and claims of personal injury or property damage caused to others by the child, including injury or damage to YMCA property or personnel.

I understand the financial requirements, registration, payment obligations and deadlines as outlined.

I have read the above and agree to the terms and conditions.

______

Signature of Parent/Guardian

Date