YMCA Registration YMCA Registration Primary MemberName* First Last Date of Birth* MM slash DD slash YYYY Gender* Male Female Address* Street Address Address Line 2 City New YorkAlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Home Phone / Primary Phone*Cell / Other PhoneEmail Emergency Contact (required)Name First Last Emergency PhoneSecondary MemberName First Last Date of Birth* MM slash DD slash YYYY Gender* Male Female Home Phone / Primary Phone*Cell / Other PhoneEmail Emergency Contact (required)Name First Last Emergency PhoneHow did you hear about the YMCA? Radio Email Friend/Family Billboard Newspaper Medical Referral Drive by Place of Employment Social Media YMCA Member Mail Former Member Other Children's InformationChildren's InformationNameDate of BirthGender Consent* I agreeWaiver, 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.