CHILDS
NAME: __________________________________________ PHONE: _________________<=
/o:p>
ADDRESS:
_________________________________________ CITY: _______________________<=
o:p>
AGE:
_____ DATE OF BIRTH:
_____________ SESSION: 1=
&nb=
sp; 2 &nb=
sp;
&nb=
sp; &n=
bsp; =
; &n=
bsp; =
; =
SHIRT
SIZE: &nb=
sp; Youth
Small (6/8) &n=
bsp;
Youth Medium (10/12) &n=
bsp;
Youth Large (14/16)
&n=
bsp; =
;
Adult Small Adult
Medium &n=
bsp;
The
Junction City Family YMCA does not provide medical or
accident insurance for any youth programs. It is the responsibility of the
participant's parents or legal guardian to provide such insurance if
desired. In consideration=
of my
acceptance in these programs, I do, release and forever discharge, the
Junction City Family YMCA, its officers, employees and agents, and its =
successors
and assigns from any and all claims of demands which I may have or might
have at any time now or in the future, arising or resulting directly fr=
om
my child's participation in these programs, including but not limited to
any illness, injury, or occurrence arising there from. Furthermore, I declare my chil=
d to
be in good medical condition for the participation in the above program=
. It is the Junction City Family
YMCA's policy that all children wanting to participate in any YMCA spor=
ts
program and can't afford to pay the fee, the YMCA will waive the fee. A $5.00 processing fee is char=
ged
for any refund.
PRINT
PARENT OR GUARDIAN NAME:_____________________________________________ <=
o:p>
SIGNATURE
OF PARENT OR GUARDIAN: ___________________________________________
RELATIONSHIP
TO PARTICIPANT: ______________________________ DATE: ___________
E-MAIL ADDRESS OF PARENT OR GUARDIAN&=
shy;&=
shy;:
&=
shy;_______________________________=
_______
Please Return Form to: &nb=
sp; Junc=
tion City Family YMCA
&nb=
sp; &nb=
sp; =
&nb=
sp; =
1703 McFarland Road<=
/st1:Street>
&nb=
sp; =
&nb=
sp; =
&nb=
sp; =
Junction City=
, 66441
&n=
bsp;
&n=
bsp; =
; &n=
bsp; =
; Phone: (785)
762-4780 &=
nbsp; &nbs=
p; &=
nbsp;
=
<=
o:p>