Four Core Values of the YMCA
Jefferson City Area YMCA
Holiday Care Registration

Please complete the following form to register for this YMCA program.

Please note the following:

  • Registration is not final until you are contacted by a YMCA employee to confirm your information is correct and that there is space available in the class/program.
  • All items marked with an asterisk (*) must be filled out to complete your registration.
  • This form works best when JavaScript is enabled.
Program Participant Information
Please enter the following information for the person that will be participating in this class.
* First Name:
* Last Name:
* Sex:
  
* Date of Birth:
/ / (Example: 06/25/2004)
* YMCA Member:
  
* School:
* Grade:
*My child has permission to swim. My child's swimming ability is:

*From the list below, please enter the days your child will attend Holiday Care:
October 22
October 29
November 24
December 23
December 27
December 28
December 29
December 30
December 31
January 3
January 17
February 18
February 21
March 14
March 15
March 16
March 17
March 18
April 22



Participant Information
If you are registering more than one participant, you will need to complete a separate registration for each child.
Parent / Guardian Information
Please enter the following information for a parent/guardian of the participant. If participant is 18 years old or older, please just enter participant information again.
* First Name:
* Last Name:
* Street Address:
* City:
* State:
* Zip:
* Home Phone:
( ) -
Cell Phone:
( ) -
Work Phone:
( ) -
* Email Address:

Parent Information
If you enter your email address, you will receive an email confirmation of this registration.

Please include as many phone numbers as possible as you will be the primary emergency contact for this participant.
Additional Emergency Contact
First Name:
Last Name:
Relationship to Program Participant:
Phone:
( ) -

Emergency Contact
Please list another contact in case you are unavailable during an emergency.
Credit Card Information
Your credit card will be charged the appropriate rate listed at the top, based on the session and YMCA membership.
* Credit Card Type:
* Credit Card Number:
- - -
* Credit Card Verification Number:
(On back of credit card)
* Expiration Date:
/
* Name on Credit Card:
If you do not wish to register with a credit card online, please print off form and mail in with payment. You can also register at the front desk at either YMCA location.

Credit Card
You must complete all information for us to process your online registration.
Liability Release
I request permission to enter the Jefferson City Area YMCA (herinafter "YMCA") in Cole County, Missouri and to participate in any YMCA activities including but not limited to YMCA Fitness Center and all sporting and recreational activities associated with the YMCA (hereinafter "YMCA activities"). I know and I assume any and all risks related to my participation in the above activities, whether such risks arise while on or off the YMCA premises.
In consideration of the permission granted to enter the YMCA premises and/or participate in the aforementioned YMCA activities, I release and discharge the owners, operators, and sponsors, as well as, all other persons in any way related to the YMCA from all claims, demands, damages, actions and causes of action (present or future, whether known or unknown, anticipated or unanticipated) for any and all personal injuries and/or damages to my property relating to my presence on the YMCA premises and/or participation in any YMCA activities to the extent those injuries and damages arise from the negligence of any fault of the YMCA.
I represent and certify that I am 18 years of age or older, and that my attendance and participation in YMCA activities is voluntary.
*


Final Review
Your registration is not complete until you have checked the box indicating you have reviewed and agree to the liability release.

Registration is not final until you are contacted by a YMCA employee to confirm your information is correct and that there is space available in the class/program.




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