Student's Name ____________________________ Grade ________

Address __________________________________ Phone______________________

Emergency number _________________________ Amount paid ________________

PROGRAM WAIVER
The undersigned has been informed that the Jefferson Family YMCA does not provide accident, health, medical
or disability insurance for the protection of those who participate in recreation programs sponsored by the
Jefferson Family YMCA.

Accordingly, I ______________________________(Parent or Guardian) give my permission
for _______________________________(Name) to participate in the Jefferson Family
YMCA __________________________________(Class). I assume all risks and hazards of the conduct of the
program. I shall defend, indemnify and hold the YMCA, its officers, employees and volunteers harmless from
any and all claims, injuries, damages, losses or suits including attorney fees, arising out
of or in connection with this activity, except for injuries and damages caused by the sole negligence of the
YMCA. Furthermore, emergency medical attention may be administered to the participant in case
of injury, accident or illness. The undersigned is responsible for the payment of all fees associated with the
above class or activity.

Parent or Guardian __________________________ Date ________________________

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Please return this application and registration fee to your school office. Make check payable to: Jefferson Family YMCA. No cash please.

Student's Name ____________________________ Grade ________

Address __________________________________ Phone_____________________

Emergency number _________________________ Amount paid________________

PROGRAM WAIVER
The undersigned has been informed that the Jefferson Family YMCA does not provide accident, health,
medical or disability insurance for the protection of those who participate in recreation programs sponsored
by the Jefferson Family YMCA.
Accordingly, I ______________________________(Parent or Guardian) give my permission
for _______________________________(Name) to participate in the Jefferson Family
YMCA __________________________________(Class). I assume all risks and hazards of the conduct of the
program. I shall defend, indemnify and hold the YMCA, its officers, employees and volunteers harmless
from any and all claims, injuries, damages, losses or suits including attorney fees, arising out
of or in connection with this activity, except for injuries and damages caused by the sole negligence of the
YMCA. Furthermore, emergency medical attention may be administered to the participant in case
of injury, accident or illness. The undersigned is responsible for the payment of all fees associated with the
above class or activity.

Parent or Guardian __________________________ Date ________________________