Y-Corps Leadership Trip to Memphis: Registration form
Student Name
*
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Gender
Male
Female
Student Date of Birth
Grade
School
Student Email
*
example@example.com
Emergency Contact 1
*
First Name
Last Name
Emergency Contact 1
*
-
Area Code
Phone Number
Emergency Contact 1
*
example@example.com
Emergency Contact Relation
Emergency Contact 2
First Name
Last Name
Emergency Contact 2
-
Area Code
Phone Number
Emergency Contact 2
example@example.com
Emergency Contact 2 Relation
Does student have medical condition that we should know about
If student has any allergies, please list below
If the student has any food restrictions, please list below
If you are YMCA member, please select your home branch.
Bethany YMCA
Chickasha YMCA
Earlywine Park YMCA
Guthrie YMCA
Gaylord Downtown YMCA
Main Street/Midtown YMCA
YMCA Healthy Living Center - Integris
Mitch Park YMCA
Midwest City YMCA
Northside YMCA
Rankin YMCA
Rockwell Plaza/ Rockwell Crossings YMCA
Not currently a Y Member
Other
Student T Shirt size
*
Small
Medium
Large
XL
2XL
3XL
By agreeing and signing below, I am agreeing and have read carefully to all of the above areas: Code of Conduct,Permission for Transport, Authorization for Emergency Medical Care, Hold Harmless Agreement and Photo and Video/Audio Recording Release. We will also provide a paper copy to be signed before departure.
By agreeing & signing this form, I am committing to pay the dues for the Y- Corps Trip to Memphis, Tennessee on June 10 - June 14 with the YMCA of Greater Oklahoma City. Please understand the Deposit Fee is non refundable
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