YMCA Registration - City Swim Project

Primary Member

Name*

First Last

Date of Birth*

Gender*

Male
Female

Address*

Street Address Address Line 2 City State ZIP Code

Home Phone / Primary Phone*

Cell / Other Phone

Email

Emergency Contact (required)

Name

First Last

Emergency Phone

Secondary Member

Name

First Last

Date of Birth*

Gender*

Male
Female

Home Phone / Primary Phone*

Cell / Other Phone

Email

Emergency Contact (required)

Name

First Last

Emergency Phone

How did you hear about the YMCA?

Children's Information

Name	Date of Birth	Gender

Consent*

I agree

Waiver, Release, and Hold Harmless I understand that YMCA Buffalo Niagara activities have inherent risks and I hereby assume all risks and hazards incident to my participation in all YMCA Buffalo Niagara activities. I further waive, release, absolve, indemnify, and agree to hold harmless YMCA Buffalo Niagara, its directors, officers, trustees, employees, volunteers, participants, coaches, referees, as well as individuals transporting participants to and from activities, from any claims arising from, or injury sustained during, my participation in activities offered by YMCA Buffalo Niagara or during my use of YMCA Buffalo Niagara property. The YMCA conducts regular sex offender screenings on all members, participants, and guests. If a sex offender match occurs, the YMCA reserves the right to cancel membership, end program participation, and remove visitation access.