Registration form

1. YMCA Camp Oakasha Parent & Me Sports– Fall 2014 Registration
Participant Name _____________________ Sex (M/F) _________ Birth Date_________
Parents Names ________________________________________________________________
Address____________________________ City________________ Zip Code _______________
Email:______________________________ Phone ______________________________
Emergency Contact _____________________ Relationship _______________________________
Emergency Phone # __________________
Circle Choice: Sports Spectacular Parent & Me Soccer Rookies Soccer
Cost: $45 for Y Members/$55 for non-members Member_______ Non-Mem _______ (please check)
DEMOGRAPHIC INFORMATION- As a non-profit agency, the YMCA relies on various federal and local funding sources that require the following information as part of the grant application process. All information is confidential.
Household Income: Below $15,000 $15,000-24,999 $25,000-39,999 $40,000-54,999 $55,000+
Race: White African-American Asian Native American Hispanic Other
How did you hear about us? Y Program Guide Patch.com Facebook Flyer Other _________
Interested in finding out about a YMCA membership and what it has to offer you?
______Yes! I would love to find out about a YMCA membership
______ Not right now but I’ll keep it in mind
Participant specifically assume all risks of injury arising out of his/her presence on the premises of the Young Men’s Christian Association (the “YMCA”), my use of its equipment or facilities and my participation in activities, weather on its premises or at another location, and for myself and my heirs and assigns hereby waive, release and agree to hold free from all claims for damages the Young Men’s Christian Association and its offices, directors, members, employees or agents. I understand the risks and dangers involved in participating in the programs and activities of the YMCA, am physically capable of participating in such programs and agree not to participate in any activity that may injure myself or others. My signature also indicates my permission to use any pictures or any other media for promotional purposes.
Signature_________________________________________ Date______________________
Staff Name_________________________ Receipt#________ Payment Type__________