Four Core Values of the YMCA
Jefferson City Area YMCA
Referee Clinic Registration

Please complete the following form to register for this clinic.

Dates: March 1 & 2
Time: 1:00 a.m. - 5:00 p.m.
Location: Knowles YMCA Annex, Lower Level
Fee: $50 per person

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.
Select Clinic
Please select your clinic.
* Clinic:
Referee Clinic
If you have any questions about the clinic, please contact Kim Boessen.
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:
  
* Street Address:
* City:
* State:
* Zip:
* Home Phone:
( ) -
Cell Phone:
( ) -
Work Phone:
( ) -
* Email Address:

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