Complimentary Swim Access Lessons for children, teens and adults

Parent/Guardian Name*

First NameLast Name
Parent/Guardian Birthdate*

MonthDayYear
Date
Parent/Guardian Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent/Guardian Preferred Phone Number*
Please enter a valid phone number.
Parent/Guardian Email*
example@example.com
Name of Referring Organization*

River Forest LibraryOak Park River Forest Community FoundationSchool District 89School District 90Other

Permissions and Authorizations
Photo/Video Permission Authorization*

I give permission for my child(ren) to have their picture and/or video taken as part of the West Cook YMCA Program. I understand that the picture or video may be used for West Cook YMCA marketing and communications including but not limited to using within the facility, newspapers, or other media outletsI DO NOT give permission for my child(ren) to have their picture and/or video taken for the purpose of West Cook YMCA marketing and communications including but not limited to using within the facility, newspapers, or other media outlets
Hold Harmless Indemnification Authorization*

I agree that the West Cook YMCA shall not be responsible for any personal injuries or losses sustained by me/my child while on any YMCA premises or as a result of YMCA sponsored activities. I further agree to idemnify and hold harmless the West Cook YMCA from any claims or demands arising out of any such injuries or losses. If I am asked, I also agree to leave the facility due to inappropriate behavior as defined by the YMCA staff. A refund will not be given if asked to leave.
I give authorization based on the above marked boxes. *

Clear
Date of Signature*

MonthDayYear
Date
Should be Empty:

Complimentary Swim Lesson Interest Form