Clone of Financial Assistance Application

YMCA Sober Strong Membership Application

A specialized program at the Eau Claire Downtown YMCA for men and women in recovery from substance use disorder. Sober Strong combines group exercise with group support meetings to create connection and belonging. Individuals can complete the registration form, and the YMCA will reach out to you to get your membership and provide you the additional details on ways to sign up for the meetings.

Name of Applicant:

First NameLast Name
Please choose one of the following:
Briefly state why you believe you would benefit from Sober Strong.
Do you have limitations regarding aerobic exercise?
Which support groups are you interested in attending?
Do you have any questions, comments, or concerns?
Personal Information
Primary Account Holder (must be 18 or older)

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Date of Birth

MonthDayYear
Date
Phone Number

Area CodePhone Number
E-mail
Emergency Contact
Name

First NameLast Name
Phone Number

Area CodePhone Number
Additional Family Information

Must live in the same household
OPTIONAL: Secondary Account Holder (must be 18 or older)

First NameLast Name
Date of Birth (REQUIRED TO ADD SECONDARY ACCOUNT HOLDER)

MonthDayYear
Date
Phone Number (REQUIRED TO ADD SECONDARY ACCOUNT HOLDER)

Area CodePhone Number
E-mail (REQUIRED TO ADD SECONDARY ACCOUNT HOLDER)
example@example.com
All Persons Living In Household

Please list all adults and children living in the household and if you would like to include them on the membership.
First NameLast NameBirthdateGender
Include on Membership?
First NameLast NameBirthdateGender
Include on Membership?
First NameLast NameBirthdateGender
Include on Membership?
First NameLast NameBirthdateGender
Include on Membership?
First NameLast NameBirthdateGender
Include on Membership?
First NameLast NameBirthdateGender
Include on Membership?
Notes regarding household:
optional

I certify that the information I have submitted is true and complete to the best of my knowledge.
Signature of person completing this form

Membership and Program Policies and Agreements

Signature required
RELEASE, INDEMNIFICATION AND HOLD HARMLESS AGREEMENT

In consideration of participating in YMCA of the Chippewa Valley activities, and for other good and valuable consideration, I hereby agree to release and discharge from liability arising from negligence the YMCA of the Chippewa Valley and its owners, directors, officers employees, agents, volunteers, participants, and all other persons or entities acting for them (hereinafter collectively referred to as “Releasees”), on behalf of myself and my children, parents, heirs, assigns, personal representative and estate, and also agree as follows:1. I acknowledge that participating in INSURED activities, including onsite, virtual, and pre-recorded on video activities, involves known and unanticipated risks which could result in physical or emotional injury, paralysis or permanent disability, death, and property damage. Risks include, but are not limited to, broken bones, exposure to our contracting of communicable diseases, torn ligaments or other injuries as a result of falls or contact with other participants; death as a result of drowning or brain damage caused by near drowning in pools or other bodies of water; medical conditions resulting from physical activity; and damaged clothing or other property. I understand such risks simply cannot be eliminated, despite the use of safety equipment, without jeopardizing the essential qualities of the activity.2. I expressly accept and assume all of the risks inherent in this activity or that might have been caused by the negligence of the Releasees. My participation in this activity is purely voluntary and I elect to participate despite the risks. In addition, if at any time I believe that event conditions are unsafe or that I am unable to participate due to physical or medical conditions, then I will immediately discontinue participation.3. I hereby voluntarily release, forever discharge, and agree to indemnify and hold harmless Releasees from any and all claims, demands, or causes of action which are in any way connected with my participation in this activity, or my use of their equipment or facilities, arising from negligence. This release does not apply to claims arising from intentional conduct. Should Releasees or anyone acting on their behalf be required to incur attorney’s fees and costs to enforce this agreement, I agree to indemnify and hold them harmless for all such fees and costs.4. I represent that I have adequate insurance to cover any injury or damage I may suffer or cause while participating in this activity, or else I agree to bear the costs of such injury or damage myself. I further represent that I have no medical or physical condition which could interfere with my safety in this activity, or else I am willing to assume – and bear the costs of – all risks that may be created, directly or indirectly, by any such condition.5. In the event that I file a lawsuit, I agree to do so in the state where Releasees’ facility is located, and I further agree that the substantive law of that state shall apply.6. I agree that if any portion of this agreement is found to be void or unenforceable, the remaining portions shall remain in full force and effect.
I have read and understand the RELEASE, INDEMNIFICATION AND HOLD HARMLESS AGREEMENT
By signing this document,

I agree that if I am hurt or my property is damaged during my participation in these activities, whether onsite, video, recorded, virtual, or otherwise, then I may be found by a court of law to have waived my right to maintain a lawsuit against the parties being released on the basis of any claim for negligence. I have had sufficient time to read this entire document and, should I choose to do so, consult with legal counsel prior to signing. Also, I understand that this activity might not be made available to me or that the cost to engage in this activity would be significantly greater if I were to choose not to sign this release, and agree that the opportunity to participate at the stated cost in return for the execution of this release is a reasonable bargain. I have read and understand this document and I agree to be bound by its terms.
Signature

Sober Strong is offered at no cost to those who need it, thanks to the generosity of individuals and organizations who support the YMCA Annual Campaign. Their gifts make it possible to provide memberships and program scholarships, ensuring this program remains accessible to all.

We invite you to help us say thank you by writing a personal note that we can share with a donor.

You don’t need to include your name, but we encourage you to share a little about yourself or your family and what this program—and your scholarship membership—means to you.
Dear YMCA Donor,
Sincerely,

A Thankful Member
Stories can inspire others to donate to this program. Can we contact you to ask for testimonials about why Sober Strong is important to you? Your privacy will be protected - we will only use your first name and city with your permission.

Other
Should be Empty:

YMCA Sober Strong Membership Application

Personal Information

Emergency Contact

Additional Family Information

All Persons Living In Household

Membership and Program Policies and Agreements

RELEASE, INDEMNIFICATION AND HOLD HARMLESS AGREEMENT

By signing this document,