REGISTRATION FORM
Participant name:                                             Parent(s) Name:
Date of birth:
Parent(s) date of Birth:
Address:
Daytime phone:
  Evening phone:
Cellular or pager:
  Parent's name:

Youth League Info:
 		    
Grade / age group:
Friend request:
Coach request:

Waiver of Liability and Hold Harmless Agreement:                                                                    I, __________________________give my permission for my child or myself (18 and older) to participate in YMCA programs offered by the Shawnee family YMCA, and agree to hold harmless the Shawnee Family YMCA, their officers, agents, or employees from any and all liability, claims, demands, actions and causes of action whatsoever arising out of or related to any loss, damage, or injury, including death, that may be sustained by me, or any of my heirs, or the property belonging to me, whether caused by the negligence of the releasees, or otherwise, while participating in such activity, or while in, on or upon the premises where the activity is being conducted. I understand that the YMCA does not maintain any insurance policy covering any circumstances arising from my participation in this program. As such, I am aware that I should review my personal insurance portfolio. In signing this release, I acknowledge and represent that I have read the foregoing Waiver of Liability and Hold Harmless Agreement, understand it and sign it voluntarily as my own free act and deed. I am at least 18 years of age and fully competent; and I execute this release for full, adequate and complete consideration fully intending to be bound by same.
 
Print name:_____________________Signature:__________________Date:_________
Please complete below for each class:

 
Class:
Member:
Program member:
Cost:
Class:
  Member:
  Program member:
Cost:
Class:
  Member:
  Program member:
Cost:
Class:
  Member:
  Program member:
Cost:
Class:
  Member:
  Program member:
Cost:
Payments:     Total:$_________________
 
Mail-in registrations: Check or money order
Phone-in registrations:   VISA, Mastercard
Walk-in registrations:   Cash, Check,VISA, Mastercard

ALL PAYMENTS DUE PRIOR TO FIRST CLASS, CAMP OR LEAGUE MEETING.

*Note: Some classes or programs have weekly or monthly fees. Check listing for specified payment period.

Refund policy: Please see promotional tabloid for refund policy.

Shawnee Family YMCA
700 W. Saratoga
Shawnee, OK 74801
405 273-4386