I hereby certify that my child is in good health and is capable of participating in the Schenectady YMCA Youth Sports program. I understand the potential risks of participation and hold harmless Proctors, the YMCA, their staff, directors, and volunteers from accidents resulting from participation. I authorize, in a medical emergency, after reasonable effort has been made to notify parents, that a YMCA representative may seek emergency assistance at the parent/guardian’s expense.

I support YMCA Youth Sports philosophy, which is based on participation, fun physical fitness and health, skill development, teamwork, fair play, family involvement, and volunteer leadership, and will uphold that philosophy through my behavior during the season. I give permission for the Schenectady YMCA to take and use video and/or photographs of myself and/or my children for the purpose of Schenectady YMCA programs.

Child's Name: *

Date of Birth: *

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Address: *

Child's Address

City: *

Child's City Address

Zip Code: *

Child's Zip Code

Gender: *

Male

Female

Parent/Guardian Name: *

Date of Birth: *

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Parent/Guardian Date of Birth

Cell/Home Phone: *

Parent/Guardian Phone

Email: *

Address: *

Parent/Guardian Address

City: *

Parent/Guardian City

Zip Code: *

Parent Zip Code

2nd Parent/Guardian Name: *

Phone: *

2nd Parent/Guardian Phone

Parent's Marital Status: *

Married

Divorced*

Single

Widowed

If separated or divorced, who has legal custody*?

*A court order is needed if a parent is denied access to a child.

EMERGENCY CONTACT: Name: *

Emergency Contact

EMERGENCY CONTACT: Relationship: *

Emergency Contact

EMERGENCY CONTACT: Phone Number: *

PICK-UP/EMERGENCY CONTACT AUTHORIZATION I authorize the proceeding people to pick up my child for the YMCA Program. I also authorize these people to be contacted in an emergency situation if the parent/legal guardian cannot be reached. All authorized persons must be at least 16 years of age and be prepared to show PHOTO ID. *Any additions to the pick-up list must be made in writing. No verbal authorizations will be accepted.

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Any Additional Notes:

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