Titusville YMCA Tiny Tumblers Gymnastics (Ages 3-5) - March 2021 Registration

Please complete a separate form for each child you are registering.

Ages 3-5
March 1-29
Mondays 5-5:45pm

YMCA Member Price = $20
YMCA Non-Member Price = $40
Please call the YMCA (814-827-3931) or stop by the YMCA to make a payment. Your registration is not complete until payment has been received.
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Participant Information
Last Name *
First Name *
Is the participant a current Titusville YMCA Member?
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Membership Info
Membership benefits include discounted program and class fees and member only programs.

FYI: If your child participates in YMCA programs throughout the year, the cost is generally less expensive for both the YMCA membership and the member program fee rather than paying the non-member program fee.

Other youth programs happening this winter - Pre-School Basketball, Pre-School Soccer, Jr NBA Basketball, Gym Games, Kids Night Out, Homeschool Gym

YMCA Membership Rates can be found on our website: https://titusvilleymca.org/rates

Financial Assistance is available, more info on the website or you can stop by the Y.
Age *
Birthdate: *
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Gender
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Address: *
City *
State *
Zip Code *
Phone Number *
Allergies/Medical Condition(s): *
The Titusville YMCA carries secondary insurance on all participants with substantial deductibles and which requires the use of your own primary health insurance to pay first and to its limit and after the exhaustion of all other coverage for which the participant may be eligible plus applicable deductibles before any payment will be made. I understand that in lieu of a primary health or accident policy, I, as parent/legal guardian with legal responsibility for this participant, am required and will accept full financial responsibility for any injury my child may incur while on the Titusville YMCA premises or while participating in any activity at or sponsored by the Titusville YMCA. *
Required
Parent/Guardian and Emergency Contact Information
Parent/Guardian Name: *
Parent/Guardian Primary Phone: *
Parent/Guardian Secondary Phone:
Parent/Guardian Email (please provide an email address if you have one)
Parent/Guardian Address (if different than child)
Other Parent/Guardian Name:
Other Parent/Guardian Primary Phone:
Other Parent/Guardian Secondary Phone:
Other Parent/Guardian Email:
Other Parent/Guardian Address (if different than child)
Emergency Contact Name (in case we are not able to get a hold of a parent/guardian): *
Participant's Relationship to Emergency Contact: *
Emergency Contact Phone: *
Medical Attention Release
I hereby release the Titusville YMCA staff to render temporary first aid to my child in the event of an injury or illness, and if deemed necessary by the Titusville YMCA staff, to call 911 and seek medical help, or call an ambulance for said child. *
Required
Photo/Video Release
I give permission to the Titusville YMCA to use photos/videos of my child for news releases, promotions, and publications. *
Passenger Waiver of Liability
If I choose to allow my child/ward to travel with an individual other than myself to and from Titusville YMCA related events and activities, I recognize that I am doing so voluntarily. I assume all risks associated with this travel and agree to absolve, exonerate, and hold harmless the Titusville YMCA and/or its institutions, Board of Directors, employees, and individuals driving from liability for any harm or injury resulting from this travel. These risks include, but are not limited to any and all injuries to my child/ward and all property damage or loss associated with this travel. *
Required
Minor Participant Waiver
Minor Participant Waiver, Release, Indemnification of All Claims & Covenant Not to Sue

PLEASE READ CAREFULLY. THIS DOCUMENT AFFECTS YOUR LEGAL RIGHTS AND IS LEGALLY BINDING. BY SIGNING THIS AGREEMENT YOU ARE RELEASING TITUSVILLE YMCA FROM ALL LIABILITY AND FOREVER GIVING UP ANY CLAIMS THEREFOR
Assumption of Risk
I, in my legal capacity as parent/guardian of the minor named below (“Minor”), acknowledge and agree that any use of Titusville YMCA facilities, services, equipment and premises (“Facilities”) and any participation in Titusville YMCA programs and activities (“Programs”) comes with inherent risks including, but in no way limited to: (1) moderate and severe personal injury, (2) property damage, (3) disability, (4) death, and (5) sickness or disease. I voluntarily, for myself and Minor, accept and assume full responsibility for these risks as well as any and all other risks of the use of Facilities and participation in Programs. I agree that I have full knowledge of the nature and extent of all such risks and am not relying on all such risks being described in this document.

Waiver, Release, Indemnification & Covenant Not to Sue
In consideration of Minor’s use of Facilities and participation in Programs, I, in my legal capacity as parent/guardian of Minor, agree on behalf of myself and Minor that the Titusville YMCA, its officers, directors, agents, employees, volunteers, insurers and representatives (“Releasees”) will not be liable for any personal injury, property damage, disability, death, sickness or disease incurred by Minor, however occurring including, but not limited to, the negligence of Releasees. I understand that Minor and I will be solely responsible for any loss or damage, including personal injury, property damage, disability, death, sickness or disease sustained from the use of Facilities and participation in Programs.

I further agree, in my legal capacity as the parent/guardian of Minor, on behalf of Minor, myself, and any and all legal successors and proxies, to release and HEREBY DO RELEASE, WAIVE AND COVENANT NOT TO SUE Releasees from any causes of action, claims, suits, liabilities or demands of any nature whatsoever including, but in no way limited to, claims of negligence, which Minor, myself, and any and all legal successors and proxies may have, now or in the future, against Releasees on account of personal injury, property damage, disability, death, sickness, disease or accident of any kind, arising out of or in any way related to the use of Facilities or participation in Programs, whether that participation is supervised or unsupervised, however the injury or damage occurs, including, but not limited to, the negligence of Releasees.

In further consideration of the use of Facilities and participation in Programs, I, in my legal capacity as parent/guardian of Minor, agree on behalf of myself and Minor to INDEMNIFY AND HOLD HARMLESS Releasees from any and all causes of action, claims, demands, losses, suits, liabilities or costs of any nature whatsoever, including claims of negligence, arising out of or in any way related to the use of Facilities and participation in Programs.

By checking below, you are indicating that you agree to the Minor Participant Waiver. *
Required
As the parent/guardian, by checking this box and typing my name below, I agree that I am electronically signing this document. *
Required
Parent/Guardian Signature *
Date *
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