Participant Intake | YMCA of Auburn-Lewiston

Participant Intake Form

YMCA of Auburn-Lewiston
This intake is for first-time participants only! Please fill in the following information so we can add you to our online registration portal. Members and past participants can skip this step and proceed directly to alymca.org/register.
There are no active registrations for youth sports at this time. This form is currently offline. Please visit alymca.org/youth-sports for more information.
Select your program of interest:
- Child's Name
  
  First NameLast Name
- Child's DOB
  
  MonthDayYear
  Date of Birth
- Child M/F
- Child's Age
- Parent/Guardian 1 Name
  
  Parent 1 First NameParent 1 Last Name
- P1 DOB
  
  MonthDayYear
  Parent 1 Date of Birth
- P1 M/F
- P1 Email
  Parent 1 Email Address
- P1 License No
  Parent 1 Driver's License Number
- P1 License State
  Parent 1 Driver's License State of Issue
- P1 Primary Phone
  Parent 1 Preferred Phone NumberFormat: (000) 000-0000.
- Primary Phone Type
- P1 Secondary Phone
  Parent 1 Backup Phone NumberFormat: (000) 000-0000.
- Secondary Phone Type
- P1 Employer Name
  Parent 1 Place of Work
- Parent/Guardian 2 Name
  
  Parent 2 First NameParent 2 Last Name
- P2 DOB
  
  MonthDayYear
  Parent 2 Date of Birth
- P2 M/F
- P2 Email
  Parent 2 Email Address
- P2 License No
  Parent 2 Driver's License Number
- P2 License State
  Parent 2 Driver's License State of Issue
- P2 Primary Phone
  Parent 2 Preferred Phone NumberFormat: (000) 000-0000.
- Primary Phone Type
- P2 Secondary Phone
  Parent 2 Backup Phone NumberFormat: (000) 000-0000.
- Secondary Phone Type
- P2 Employer Name
  Parent 2 Place of Work
- Household Address
  
  Street Number & Address
  
  Street Address Line 2
  
  CityState
  
  Zip Code
- Our family receives mail at:
- Mailing Address (if different than household)
  
  Street Number & Address
  
  Street Address Line 2
  
  CityState
  
  Zip Code
- Emergency contact must be someone other than the parents.
- Emergency Contact
  
  Full Name
  
  Street Address Line 2
  
  Phone NumberRelationship
  
  Postal / Zip Code
- It's important that you read in full and understand the following:
  
  Photo and Video/Audio Recording Release
  
  Checking "I agree" will serve as a placeholder for your digital signature.
- Do you consent to the Photo and Video/Audio Recording Release?
- It's important that you read in full and understand the following:
  
  Release and Waiver of Liability
  
  Checking "I agree" will serve as a placeholder for your digital signature.
- YMCA of Auburn-Lewiston participants must read and consent to the following:
  - I am at least 18 years old (parent or legal guardian must sign for a minor).
  - I understand the YMCA is not responsible 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.
  - The YMCA conducts regular sex offender screenings on all members, participants, and guests. If a sex offender match occurs, the YMCA reserves the right to end program participation, and remove visitation access.
  - For security purposes, all individuals over the age of 16 are required to have a photo taken for their account at the time of joining our YMCA. If they are not present at the time of joining, they will need to stop by the front desk and have their photo taken on their first visit.
  - I hereby grant permission for my children to receive emergency medical treatment for illness or accident if I cannot first be contacted.
  - I understand that I can register for YMCA of Auburn-Lewiston programs online at alymca.org/register once this intake is reviewed and access is granted (roughly 2-3 days following submission).
- Parent/Guardian 1 Signature
- Date
  
  MonthDayYear
  Date
- Parent/Guardian 2 Signature
- Date
  
  MonthDayYear
  Date
- Verify you are human
- There are no active registrations for youth sports at this time. This form is currently offline. Please visit alymca.org/youth-sports for more information.
- Should be Empty:

Participant Intake Form