Membership Application

First Name *

Last Name *

Gender *

Male
Female
Non-Binary

Membership Type Wanted *

Pay Frequency Desired *

Monthly
Annually

Age *

Date of Birth *

Which of the following best describes you *

Why do we ask? This information helps us better understand the community we serve.

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Phone *

Email *

Place of Employment *

Occupation *

Spouse Name *

First

Last

Spouse Date of Birth *

Number of Kids *

Child's Name *

First

Last

Child Date of Birth *

Child's Name *

First

Last

Child Date of Birth *

Child's Name *

First

Last

Child Date of Birth *

Child's Name *

First

Last

Child Date of Birth *

Child's Name *

First

Last

Child Date of Birth *

Child's Name *

First

Last

Child Date of Birth *

Emergency Contact *

First

Last

Emergency Contact Phone *

Photo ID (Government Issued ID) *

Click or drag a file to this area to upload.

Signature *

Todays Date *

Participant Release & Waiver of Liability and Indemnity Agreement *

I have read and agree to the terms below

PLEASE READ CAREFULLY. THIS DOCUMENT EFFECTS YOUR LEGAL RIGHTS AND IS LEGALLY BINDING. BY SIGNING THIS AGREEMENT YOU ARE RELEASING THE SOMERVILLE YMCA FROM ALL LIABILITY AND FOREVER GIVING UP ANY CLAIMS THEREFORE. Assumption of Risk I acknowledge and agree that any use of Somerville YMCA facilities, services, equipment and premises (“Facilities”) and any participation in Somerville YMCA programs and activities (“Programs”) comes with inherent risks including, but in no way limited to: (1) moderate and severe personal injury, (2) property damage, (3) disability, (4) death, and (5) sickness or disease. I voluntarily accept and assume full responsibility for these risks as well as any and all other risks of the use of Facilities and participation in Programs. I agree that I have full knowledge of the nature and extent of all such risks and am not relying on all such risks being described in this document. Waiver, Release, Indemnification & Covenant Not to Sue In consideration of the use of Facilities and participation in Programs I, the undersigned, agree that the Somerville YMCA, it’s officers, directors, agents, employees, volunteers, insurers and representatives (“Releasees”) will not be liable for any personal injury, property damage, disability, death, sickness or disease incurred by myself, my family members, dependents, or guests, including minors, however occurring including, but not limited to the negligence of Releasees. I understand that I will be solely responsible for any loss or damage, including personal injury, property damage, disability, death, sickness or disease sustained from the use of Facilities and participation in Programs. I further agree, on behalf of myself and any and all legal successors and proxies, to release and HEREBY DO RELEASE, WAIVE AND COVENANT NOT TO SUE Releasees from any causes of action, claims, suits, liabilities or demands of any nature whatsoever including, but in no way limited to, claims of negligence, which I and any and all legal successors and proxies may have, now or in the future, against Releasees on account of personal injury, property damage, disability, death, sickness, diseases or accident of any kind, arising out of or in any way related to the use of Facilities or participation in Programs, whether that participation is supervised or unsupervised, however the injury or damage occurs, including, but not limited to the negligence of Releasees. In further consideration of the use of Facilities and participation in Programs, I agree to INDEMNIFY AND HOLD HARMLESS Releasees from any and all causes of action, claims, demands, losses, suits, liabilities or costs of any nature whatsoever, including claims of negligence, arising out of or in any way related to the use of Facilities and participation in Programs by myself, my family members, dependents or guests, including any minors.

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