Intermediate Basketball Registration

*If you are not able to access the form below after registration is open, this may be due to the class being filled. 

Child's Name *

First

Last

Parent's Name *

First

Last

Email *

Phone *

Emergency Contact *

First

Last

Is there anything the instructor should know about your child? For example: speech delay, trouble following directions, asthma, etc.

Are you a current member of the Somerville Y? *

• Yes
• No

Member Rate *

Price: $ 45.00

Non-Member Rate *

Price: $ 75.00

Payment Info (Credit Card or Debit Card) *

Card Number

MM123456789101112Expiration

/

YY2324252627282930313233

Security Code

Billing Address *

Address Line 1

Address Line 2

City

AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingState

Zip Code

Participant Release & Waiver of Liability and Indemnity Agreement *

• I have read and agree to 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.

Total

$ 0.00

Participant Signature *

Clear Signature

Submit

If the class is full, please Fill out this WAITLIST