Household Members Foster Youth's Name (this youth will be the primary member)(Required)
First
Last
Foster Youth's Date of Birth(Required) Foster Youth's Gender(Required) Primary Adult Members Name(Required)
First
Last
YMCA memberships can have up to 3 adults age 24 and older who live in the same household.
Primary Adult Member's Date of Birth(Required) Primary Adult's Gender(Required) Secondary Adult Members Name
First
Last
YMCA memberships can have up to 3 adults age 24 and older who live in the same household.
Secondary Adult Date of Birth Secondary Adult's Gender Third Adult Member's Name
First
Last
Memberships cannot have more than 3 adult members.
Third Adult's Date of Birth Third Adult's Gender Household Child 1 Name (this is not the primary member foster youth above)
First
Last
YMCA memberships can have an unlimited number of youth under the age of 24 who live in the same household.
Child 1's Date of Birth Child 1's Gender Household Child 2 Name
First
Last
YMCA memberships can have an unlimited number of youth under the age of 24 who live in the same household.
Child 2's Date of Birth Child 2's Gender Household Child 3 Name
First
Last
YMCA memberships can have an unlimited number of youth under the age of 24 who live in the same household. More household child slots will appear if you fill out the information for this child.
Child 3's Date of Birth Child 3's Gender Household Child 4 Name
First
Last
YMCA memberships can have an unlimited number of youth under the age of 24 who live in the same household. More household child slots will appear if you fill out the information for this child.
Child 4's Date of Birth Child 4's Gender Household Child 5 Name
First
Last
YMCA memberships can have an unlimited number of youth under the age of 24 who live in the same household. More household child slots will appear if you fill out the information for this child.
Child 5's Date of Birth Child 5's Gender Household Child 6 Name
First
Last
YMCA memberships can have an unlimited number of youth under the age of 24 who live in the same household. More household child slots will appear if you fill out the information for this child.
Child 6's Date of Birth Child 6's Gender Household Child 7 Name
First
Last
YMCA memberships can have an unlimited number of youth under the age of 24 who live in the same household. More household child slots will appear if you fill out the information for this child.
Child 7's Date of Birth Child 7's Gender Household Child 8 Name
First
Last
YMCA memberships can have an unlimited number of youth under the age of 24 who live in the same household. If your household has more members than can be added to this form, please contact us with their information.
Child 8's Date of Birth Child 8's Gender
Emergency Contacts Name(Required)
First
Last
Social Worker's Name (if no longer in care put N/A)(Required)
First
Last
Primary Caregiver's Address(Required)
I understand that the foster youth's account must be used the YMCA at least 10x as a household per quarter or the YMCA membership will be suspended. If you are a social worker applying for a client, you also agree to inform your client of this requirement.
YMCA OF SOUTH HAMPTON ROADS
RELEASE AND WAIVER OF LIABILITY AND INDEMNITY AGREEMENT
I am an adult over 18 years of age and wish to participate in YMCA of South Hampton Roads membership/program activities. IN CONSIDER- ATION of being permitted to utilize the facilities, services and programs of the YMCA for any purpose, including, but not limited to observationor use of facilities or equipment, or participation in any off-site program affiliated with the YMCA, the undersigned, for himself or herself and any personal representatives, heirs, and next of kin, hereby acknowledges, agrees and represents that he or she has, or immediately upon entering or participating inspected and carefully considered such premises and facili- ties or the affiliated program. In addition, I give my children permission to participate in YMCA of South Hampton Roads activities. I understand that even when every reasonable precaution is taken, accidents can sometimes happen. Therefore, in exchange for allowing me to participate in YMCA activities, I understand and expressly acknowledge that I, for myself, or anyone entitled to act on my behalf, waive and release the YMCA, spon- sors, representatives, and successors from all claims or liabilities of any kind arising out of my participation in activities at or sponsored by the YMCA. I further agree to indemnify and save harmless the YMCA from any claims or demands arising out of any such injuries or losses. I understand that this release includes any claims based on negligence, action or inac- tion of the YMCA of South Hampton Roads, its staff, directors, members and guests. I have read, understand, and am voluntarily signing this authorization and release.I understand that the YMCA of South Hampton Roads is not respon- sible for personal property lost, damaged, or stolen while members and/ or program participants are using YMCA facilities, on YMCA premises, or involved in YMCA programs.
YMCA OF THE VIRGINIA PENINSULAS
RELEASE AND WAIVER OF LIABILITY AND INDEMNITY AGREEMENT
In consideration for being permitted to utilize the facilities, services, programs, and participation in the YMCA Nationwide Membership Program of the National Council of Young Men’s Christian Associations of the United States of America, and its independent and autonomous member associations in the United States and Puerto Rico, for any purpose, including, but not limited to, observation or use of facilities or equipment, or participation in any program affiliated with the YMCA without respect to location, the undersigned, for himself or herself and any personal representatives, heirs, and next of kin, hereby acknowledges, agrees and represents that he or she has, or immediately upon entering or participation will, inspect and carefully consider such premises, facilities and affiliated program(s). It is further warranted that such entry into the YMCA or its programs for observation, or use of any facilities or equipment, or participation in such affiliated program(s) without respect to location, constitutes an acknowledgement that such premises, facilities and equipment thereon, and other such affiliated programs have been inspected and carefully considered, and that the undersigned finds and accepts same as being safe and reasonably suited for the purpose of such observation, use, or participation.
IN FURTHER CONSIDERATION OF BEING PERMITTED TO ENTER THE YMCA FOR ANY PURPOSE, INCLUDING, BUT NOT LIMITED TO, OBSERVATION OR USE OF FACILITIES OR EQUIPMENT, OR PARTICIPATION IN ANY PROGRAM AFFILIATED WITH THE YMCA WITHOUT RESPECT TO LOCATION, THE UNDERSIGNED HEREBY AGREES TO THE FOLLOWING:
1. THE UNDERSIGNED HEREBY RELEASES, WAIVES, DISCHARGES AND COVENANTS NOT SUE the YMCA, its directors, officers, employees, and agents (hereinafter referred to as “releasees”) from all liability to the undersigned, his personal representatives, assignees, heirs, and next of kin for any loss or damage and any claim or demands therefore on account of injury to the person or property or resulting death of the undersigned, whether caused by the ordinary negligence of the releasees or otherwise while the undersigned is in, upon, or about the premises or any facilities or equipment therein, or participating in any program affiliated with the YMCA, without respect to location.
2. THE UNDERSIGNED HEREBY AGREES TO INDEMNIFY, SAVE AND HOLD HARMLESS the releasees and each of them from any loss, liability, damage or cost that may incur due to the presence of the undersigned in, upon, or about the YMCA premises or in any way observing or using any facilities or equipment of the YMCA or participating in any program affiliated with the YMCA, whether caused by the ordinary negligence of the releasees or otherwise.
3. THE UNDERSIGNED HEREBY ASSUMES FULL RESPONSIBILITY FOR AND RISK OF BODILY INJURY, DEATH, OR PROPERTY DAMAGE while in, about, or upon the premises of the YMCA and/or while using the premises or any facilities or equipment thereon, or participation in any program affiliated with the YMCA.
THE UNDERSIGNED further expressly agrees that the foregoing RELEASE, WAIVER AND INDEMNITY AGREEMENT is intended to be as broad and inclusive as is permitted by the law of the State of Virginia and that if any portion thereof is held invalid, it is agreed that the balance shall, notwithstanding, continue in full legal force and effect.
THE UNDERSIGNED HAS READ, UNDERSTANDS, AND VOLUNTARILY SIGNS THE RELEASE AND WAIVER OF LIABILITY AND INDEMNITY
AGREEMENT, and further agrees that no oral representations, statements, or inducements apart from the foregoing written agreement
have been made.
YMCA of GREATER RICHMOND
The YMCA of Greater Richmond will have you sign their safety waivers when you create your online account. Instructions will be emailed to the primary caregiver once your application has been approved.
I acknowledge receipt of the safety waivers above and agree to abide by the safety guidelines therein(Required) 
