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Youth Membership Application
Youth Membership Application
John Petrella
2022-12-21T15:39:09-05:00
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Name
*
First
Last
Gender
*
Male
Female
Non-Binary
Age (6-17)
*
I/My Child is at least 6 years old, If younger this application will not be considered
*
I understand
Date of Birth
*
Which of the following best describes you
American Indian or Alaskan Native
Asian
Black or African American
Hispanic
White/Caucasian
Hawaiin or Pacific Islander
Middle Eastern or North African
Multiethnic
Prefer not to Answer
Why do we ask this? We ask this as it helps us better understand the community we serve.
Membership Type
*
Youth MINIMUM AGE 6
Membership Type
*
High School
Address
*
Address Line 1
Address Line 2
City
--- Select state ---
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
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Montana
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New Hampshire
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New York
North Carolina
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Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Phone
*
Email
*
School ID (High School)
*
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Emergency Contact
*
First
Last
Emergency Contact Phone
*
Signature
*
Clear 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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Somerville, MA 02143
617-625-5050
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