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MEMBER INFORMATION

Name
Address
Address
Gender
YMCA Member

DEMOGRAPHICS

Household Income
Disability
Veteran
LGBTQIA+
Race/Ethnicity

EMERGENCY CONTACTS

Must list at least one emergency contact.

Name
Name
Name

HEALTH INFORMATION

Do you have any medical conditions that we should be aware of?
Do you have any allergies that we should be aware of?

MEMBERSHIP AGREEMENT

The YMCA of Greater Rochester is not responsible for lost, stolen, or damaged items and/or personal property.

I agree to abide by the rules and regulations of the YMCA, which are designed for the enjoyment of all its members. The protection of members who are utilizing the YMCA is of paramount concern to the YMCA of Greater Rochester. Therefore, we reserve the right to deny access or membership to any person whose behavior is judged to be in conflict with the welfare and safety of other members and/or staff; has pleaded guilty to the transportation of illegal, habit forming or dangerous drugs; or who is presently clearly under the influence of intoxicating beverages or behavior modifying drugs. The YMCA conducts regular sex offender screenings on all members and staff. If a sex offender match occurs, the YMCA reserves the right to cancel membership, end program participation, and remove visitation access.

I hereby consent to and authorize the use and reproduction of any and all photographs or video footage taken of me and/or my family, including children listed on this application, for YMCA of Greater Rochester’s promotional and public relations purposes. I understand that will I receive no reimbursement for allowing my photo to be taken or for the use of the photo or video.

The use of cell phones or camera phones is not permitted in the locker rooms, wellness center, gymnasium and other program areas. Photos and videos may be taken only with the expressed permission of YMCA management and all participants being photographed. Signed photo releases must be filed with the YMCA.

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WAIVER, RELEASE, INDENTIFICATION AND HOLD HARMLESS AGREEMENT

In consideration of membership with the YMCA of Greater Rochester, I agree to release, indemnify and hold harmless the YMCA, and its officers, employees and volunteers, with respect to any and all accidents, injuries, losses or damages to person or property that result from my/my child’s participation in YMCA programs or facilities, whether arising from the negligence of the YMCA or otherwise, to the fullest extent permitted by law. I do further agree on behalf of myself, and my heirs, executors and administrators, to waive, release and forever discharge any and all rights and claims for damages which may have accrued, or which may hereafter accrue, to me/my child arising out of or connected with participation in the YMCA programs, use of the YMCA facilities and property, or use of equipment within the YMCA facilities and property.

I understand that even when every reasonable precaution is taken, accidents can sometimes occur. I further understand that the activities of the YMCA have inherent risks of serious injury and I hereby assume all such risks and hazards incidental to my or my family’s participation in the programs, use of the facilities, or use of equipment within the facilities.

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