Hamden/north Haven Ymca Typhoon Swim Team Registration Form Page 2

HAMDEN/NORTH HAVEN YMCA

Typhoon Swim Team Authorization and Release Form

I understand that my child must have either participated with the Hamden/North Haven YMCA Typhoons Swim Team in the previous seasons or attended an evaluation

session to participate on the team.

Payment Options and Authorizations:

Payment being made by (circle one): Cash

Check

Credit Card on File at the Y

Authorization for Medical Attention:

Please list all medications and/or medical conditions affecting your child. _______________________________________________________________________________________________________________________

______________________________________________________________________________________________________________________________________________________________________________________________________________________

I give permission for the YMCA Certified First-Aid staff to treat my child, if needed. I authorize the aquatics staff to consent to emergency treatment (under advice

of a Connecticut licensed physician) for my child when the need for such treatment is immediate and when efforts to contact me are unsuccessful. My child will be

transported to the nearest emergency facility. I understand that any expenses incurred, through transportation and the treatment of my child, are my responsibility.

Name of Physician

Address/Phone

_______

Insurance Company

Policy Number

_______

Policy Holder

Relationship to Child

_______

Central Connecticut Coast YMCA Member Code of Conduct:

All members must act in accordance with the values of the Y to maintain an atmosphere that is free of offensive and unlawful conduct. We show no tolerance for:

Fighting; Use of abusive language; Smoking in Y facilities and/or properties; Carrying or concealing a weapon or any device or object that may be used as a weapon

Inappropriate, immodest or sexually revealing attire (as interpreted by Y staff); Disrespect for property rights of the Y or others; Conduct or actions of a sexual nature;

Derogatory or unwelcome comments based on individuals’ sex, race, ethnicity, age, religion, marital status, citizenship, disability, sexual orientation or any legally

protected status. As a private organization, the Y reserves the right to cancel the membership of any member who does not follow the Member Code of Conduct at any

time—while on site at a Y Branch or during participation of any Y affiliated program/event regardless of location. Y staff members may define what is considered

inappropriate behavior in determination of a member’s suspension or termination. Y members or guests who observe conduct not fitting of the Member Code of Conduct

should promptly report concerns to Y staff. We will then make every effort to investigate and resolve issues promptly, confidentially and effectively. In addition, the Y

reserves the right to deny access or membership to any person who has been convicted of any crime involving sexual abuse, is or has been a registered sex offender or

is presently or habitually under the influence of dangerous drugs or chemicals, narcotics or intoxicating beverages.

Parent Agreement:

I agree to review and abide by the Central Connecticut Coast YMCA Member as a parent and to ensure my child abides by them also.

I understand that it is my responsibility and agree to volunteer in at least 1 Hamden/North Haven Y Typhoon Home Swim meet and 1 Away Swim meet, Events and

Functions as part of my commitment to the swim team.

Signature of Parent/Guardian _______________________________________________________________________________________________________________________ Date

____________________________________

08/08/2015