Health & Wellness Registration

Name:     Birth Date:

Address:

City: State: Zip:

Phone: Cell Phone:

Email Address:

Program Name:

Beginning Date:

Member or Participant: Member Participant

I hereby consent to participation in the above Yakima Family YMCA program. I also agree to indemnify and hold harmless the Yakima Family YMCA from any claims, costs, damages, liabilities or expenses resulting form injury to myself. I will follow all rules and guidelines set forth by the YMCA and conduct myself in an appropriate manner. I also give permission for the Yakima Family YMCA to use any photographs or videos of me for promotional purposes.