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Grand River Area Family YMCA
Online Registration Form
1725 Locust Street, Chillicothe, MO 64601, 660-646-6677

(One Form Per Child)

To complete registration, mail your check to 1725 Locust Street for the amount due (note on the check that it covers an online registration) or stop by the office and make payment as desired.

NOTE: You may also download this form as a PDF, print, complete, and mail in with your check. Or, bring the completed form to the YMCA with your payment.
Form Name:

Class or Program:

Child's Name:

Gender:

Male: Female:

Age:

Grade:

Date of Birth:

Home Phone:

Include Area Code
Street Address:
City:

State:   Zip:

Email Address:

Mother's Name:

Father's Name:

Mother's Work Phone: Include Area Code
Father's Work Phone:

Include Area Code
Mother's Cell Phone:

Include Area Code
Father's Cell Phone:

Include Area Code
EMERGENCY INFORMATION
Authorized Persons (other than parents) to be called in case of an emergency:
Contact Name 1:

Phone:

Relationship:

Contact Name 2:

Phone:

Relationship:

SPECIAL REQUESTS
Name of Coach:
(if applicable)

On Team With:
(if applicable)
Other:

INSURANCE
It is expressly understood that the Grand River Area Family YMCA does not insure against, nor accept responsibility for, personal injury or property loss or damage to the participant which may be sustained as a result of his/her participation. Parents or legal guardians are responsible for medical care, treatment, and insurance for said participant.

RELEASE/WAIVER
In return for allowing the above mentioned participant to play in the above mentioned youth sports program, the undersigned, to be legally bound, release and forever discharge the Grand River Area Family YMCA, Calvary Baptist Church, their agents, representatives, successors and assigns from any claims for damages, including any claims for loss, damages or injury to the participant's person or property arising out of the participant's performance or failure of performance. If the undersigned has doubts about the physical condition of said participant, a physical examination is recommended. In addition, the undersigned hereby authorizes any first aid, medical treatment deemed necessary in case of emergency for said participant during the above mentioned youth sports program and give permission for emergency treatment, x-rays, or surgery as recommended by the attending physician. I / We assume full financial responsibility for any and all medical care for said participant.

Any pictures or videotape of participant during the above mentioned youth sports program may be used for promotional purposes of the YMCA activities and programs.
Signature:
(Parent/Legal Guardian)

Note: A typed and submitted online signature is valid and legally binding.

Volunteers are an essential part to YMCA programs. If you would be interested in helping in any one of the following roles, please let us know. Your help is greatly appreciated.
Coach: YES NO
Assistant Coach:: YES NO

To complete registration, mail your check to 1725 Locust Street for the amount due
(note on the check that it covers an online registration) or stop by the office and make payment as desired.
You may also download this form as a PDF, print, complete, and mail in with your check.
Or, bring the completed form to the YMCA with your payment.

Philipians 3:14 - I press toward the goal for the prize of the upward call of God in Christ Jesus.

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