Informed Consent/Liability Waiver Agreement

GUEST REGISTRATION AND

INFORMED CONSENT/LIABILITY WAIVER AGREEMENT

Thank you for visiting the INSERT NAME YMCA. All guests must present a valid photo ID each time they visit our facility. You may visit us 3 times within a one year period before joining.

Adults Youth

$12 $6

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Name Home Phone

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Address Date of Birth

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City State Zip

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Guest of

PLEASE TURN THIS CARD OVER AND READ AND SIGN THE

INFORMED CONSENT/LIABILITY WAIVER AGREEMENT ON THE BACK OF THIS CARD

YMCA OF INSERT NAME

INFORMED CONSENT/LIABILITY WAIVER AGREEMENT

I, the undersigned, realize that there may be medical risks associated with physical exercise, the use of this facility, or the use of equipment within the facility. I/We also recognize that the YMCA cannot evaluate my/our physical abilities and medical limitations as they pertain to participation in programs, to the use of the facilities, or use of the equipment within the facility. I/WE THEREFORE ASSUME ALL RESPONSIBILITY FOR HAVING A THOROUGH MEDICAL EXAMINATION PERFORMED, BY A MEDICAL PRACTITIONER OF MY/OUR CHOICE BEFORE PARTICIPATING IN ANY PROGRAMS AND PRIOR TO USING THE FACILITIES OR EQUIPMENT WITHIN THE FACILITIES. I/WE ALSO ASSUME ALL RESPONSIBILITY FOR ABIDING BY THE RECOMMENDATIONS OF THAT MEDICAL PRACTITIONER, INCLUDING BUT NOT LIMITED TO, AS THEY PERTAIN TO LIMITATIONS ON EXERCISE, PARTICIPATION IN YMCA PROGRAMS AND USE OF YMCA FACILITIES OR EQUIPMENT WITHIN YMCA FACILITIES.

FURTHERMORE, in exchange for the YMCA allowing me/us to participate in the activities of, and use the facilities of the Young Men’s Christian Association of INSERT NAME:

I/WE AGREE TO HOLD FREE FROM ANY AND ALL LIABILITY – INCLUDING, BUT NOT LIMITED TO, LIABILITY FOR ANY OF ITS OWN NEGLIGENCE – THE YMCA OF PHILADELPHIA AND VICINITY AND/OR ANY OF ITS RESPECTIVE OFFICERS, EMPLOYEES AND MEMBERS. I/WE AGREE TO WAIVE, RELEASE AND FOREVER DISCHARGE ANY AND ALL RIGHTS AND CLAIMS FOR DAMAGES WHICH I/WE MAY HAVE OR WHICH MAY ACCRUE TO ME/US ARISING OUT OF OR CONNECTED WITH MY/OUR PARTICIPATION IN ANY OF THE ACTIVITIES OF THE YMCA OF PHILADELPHIA & VICINITY, USE OF ITS FACILITIES, OR USE OF EQUIPMENT WITHIN ITS FACILITIES; PROVIDED THAT THIS WAIVER AND RELEASE WILL NOT APPLY TO MY/OUR PARTICIPATION IN ANY OF THE YMCA’S CHILD CARE SERVICES.

I/We the undersigned, have READ, FULLY UNDERSTAND, AND AGREE TO ALL OF THE ABOVE.

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Signature of Guest or (if under 18) Date

Guardian

YMCA OF INSERT NAME

TERMS AND CONDITIONS

I agree to abide by the rules and regulations of the YMCA, which are designed for the enjoyment of all its members. The protection of members and guests who are utilizing the YMCA is of paramount concern to the YMCA. We reserve the right to deny access or membership to any person: whose behavior is judged to be in conflict with the welfare and safety of other members and/or staff; or who is a registered sexual offender; has plead guilty to or been convicted of any crime involving sexual abuse or a crime against persons such as a child, spousal or parental abuse or any offense relating to the sale or transportation of illegal, habit forming or dangerous drugs; and/or to any person who is clearly under the influence of intoxicating beverages or behavior modifying drugs.

I/We the undersigned, have READ, FULLY UNDERSTAND AND AGREE TO ALL OF THE ABOVE.

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Signature of Guest or (if under 18) Date

Guardian