Membership Application

Demographic Information

As a non-profit agency, the YMCA relies on various federal and local funding sources that require the following information as part of the grant application process. All information is confidential.

Membership Type- Please Select

**There is a maximum of two adults on the membership, if you want to add additional adults it will be $31 extra per month per member

Corporate Partners who do not qualify for payroll deduction are eligible for a 10% discount off an Adult, Family or Single Parent Family

Payment Method & Terms(please select one)

Electronic Funds Transfer (EFT Agreement)

I (we) hereby authorize the Grea ter Waterbury YMCA to charge my (our) account monthly, in the amount named, as such amounts become due without any further authorization. It is understood that this agreement shall continue indefinitely and will terminate only when authorized in writing by me (us) and when I (we) have returned my membership card. The YMCA reserves the right to adjust monthly debit entries for uncollected fees, adjust for change in membership category, and to terminate this agreement due to nonpayment of membership fees. EFT and credit card deductions are made automatically on the 15th of each month. The YMCA administers a non-sufficient fund fee of up to $30, in the event that your payment is unable to be processed. Bank processing times vary depending on your financial institution. Please note that your bank may also charge an additional non-sufficient fund fee.

The signature below states my understanding that I have agreed for the Greater Waterbury YMCA to draft the account indicated above perpetually, for the draft amount indicated above until I cancel my membership. I understand that a minimum of 30 days is required to terminate this agreement. Fees may change with 30-days’ notice. I have read and understand this agreement.

Secondary Member Information (Adult)

Children *All dependents must be under 18 and reside in the same household as the primary member. However, Children between the ages 18-25 must be enrolled in college full-time to remain on a family membership. If you like to add additional adults there will be an additional monthly charge of $ 31 per adult per month.

Agreement: Liability Waiver & Code of Conduct

I understand and agree on behalf of myself, others on my membership and/or guests, to abide by the following policies and procedures in consideration for my membership to the YMCA. The YMCA reserves the right to deny access, reject, or cancel any application or membership of any person. This includes, but is not limited to, any person known to have been accused or convicted of any crime involving child abuse, sexual abuse or is a registered sex offender. By signing this form, you certify that neither you nor anyone on your membership has been accused or convicted of a criminal offense listed above. I understand that the Greater Waterbury YMCA employees, agents, and assigns, have the right to videotape or photograph me and use my picture, voice, quotes, silhouette and other reproductions of my physical likeness (as the same may appear in any still camera photography and/or motion picture film/video), in and in connection with the advertising, promoting and communications for YMCA purposes only. I understand that while exercise is instrumental to maintaining good health, use of the facilities at the YMCA incurs some potential risk. In consideration for being allowed to participate in activities and to use the equipment and facilities at the YMCA, I assume the risk of all such usage and further agree to hold harmless the YMCA and its staff members from any and all claim suits, losses, or related causes of action for damages, including but not limited to, such claims that may result from my injury or death, accidental or otherwise, during, or arising in any way from exercising or using the facilities at the YMCA. I understand the YMCA is not responsible for lost or stolen items. I further understand the YMCA has the right to revise policies and procedures without notice.

Code of Conduct:

• Members shall act appropriately always when in the YMCA’s facility or participating in its programs.

• Members are responsible for their personal comfort and safety.

• Members should report inappropriate behavior to a staff person or the Building Supervisor on duty.

• Members shall not cause disruption to membership or programs.

• Members and/or guests shall not use the premises and/or services of the Greater Waterbury YMCA for any form of compensation.

• Members and/or guests shall identify themselves to staff when asked.

I have read and understand the liability waiver and code of conduct.

Terms of Membership Agreement

• Membership dues are non-refundable.

• Any person or family with a balance owed to the YMCA will not be permitted to participate until the balance is paid.

• A fee of up to $30 will be applied for any payments that are not paid in accordance with the draft agreement. The member is responsible for returned payment fees that are incurred.

• Members must give 30 days' notice in writing to terminate their membership after the first year.

• Members must give 14 days’ notice to freeze their membership.

• Adult YMCA members are permitted to bring 2 guests per year. The guest must bring a photo ID and give it to the MembershipRepresentative.

• Children between ages 18-25 must be enrolled in college full-time to remain on a family membership.

• Only 2 adults above the age of 18 are allowed on a family membership.

• I have read and understand the terms of the membership agreement

Adult Participant Release & Waiver of Liability and Indemnity Agreement

PLEASE READ CAREFULLY. THIS DOCUMENT AFFECTS YOUR LEGAL RIGHTS AND IS LEGALLY BINDING. BY SIGNING THIS AGREEMENT, YOU ARE RELEASING THE GREATER WATERBURY YMCA FROM ALL LIABILITY AND FOREVER GIVING UP ANY CLAIMS THEREFOR.

Assumption of Risk

I acknowledge and agree that any use of The Greater Waterbury YMCA facilities, services, equipment, and premises (Facilities) and any participation in The Greater Waterbury YMCA programs and activities (?Programs?) comes with inherent risks including, but in no way limited to: (1) moderate and severe personal injury, (2) property damage, (3) disability, (4) death, and (5) sickness or disease. I voluntarily accept and assume full responsibility for these risks as well as any and all other risks of the use of Facilities and participation in Programs. I agree that I have full knowledge of the nature and extent of all such risks and am not relying on all such risks being described in this document.

Waiver, Release, Indemnification & Covenant Not to Sue

In consideration of the use of Facilities and participation in Programs I, the undersigned, agree that The Greater Waterbury YMCA, its officers, directors, agents, employees, volunteers, insurers, and representatives (?Releasees?) will not be liable for any personal injury, property damage, disability, death, sickness or disease incurred by myself, my family members, dependents, or guests, including minors, however occurring including, but not limited to, the negligence of Releasees. I understand that I will be solely responsible for any loss or damage, including personal injury, property damage, disability, death, sickness, or disease sustained from the use of Facilities and participation in Programs.

I further agree, on behalf of myself and any and all legal successors and proxies, to release and HEREBY DO RELEASE, WAIVE AND COVENANT NOT TO SUE Releasees from any causes of action, claims, suits, liabilities, or demands of any nature whatsoever including, but in no way limited to, claims of negligence, which I and any and all legal successors and proxies may have, now or in the future, against Releasees on account of personal injury, property damage, disability, death, sickness, diseases or accident of any kind, arising out of or in any way related to the use of Facilities or participation in Programs, whether that participation is supervised or unsupervised; however, the injury or damage occurs, including, but not limited to the negligence of Releasees.

In further consideration of the use of Facilities and participation in Programs, I agree to INDEMNIFY AND HOLD HARMLESS Releasees from any and all causes of action, claims, demands, losses, suits, liabilities, or costs of any nature whatsoever, including claims of negligence, arising out of or in any way related to the use of Facilities and participation in Programs by myself, my family members, dependents or guests, including any minors.

Minor Participant Waiver, Release, Indemnification of All Claims & Covenant Not to Sue

PLEASE READ CAREFULLY. THIS DOCUMENT AFFECTS YOUR LEGAL RIGHTS AND IS LEGALLY BINDING. BY SIGNING THIS AGREEMENT, YOU ARE RELEASING GREATER WATERBURY YMCA FROM ALL LIABILITY AND FOREVER GIVING UP ANY CLAIMS THEREFORE

Assumption of Risk
I, in my legal capacity as parent/guardian of the minor named below (“Minor”), acknowledge and agree that any use of Greater Waterbury YMCA facilities, services, equipment, and premises (“Facilities”) and any participation in Greater Waterbury YMCA programs and activities (“Programs”) comes with inherent risks including, but in no way limited to (1) moderate and severe personal injury, (2) property damage, (3) disability, (4) death, and (5) sickness or disease. I voluntarily, for myself and Minor, accept and assume full responsibility for these risks as well as any and all other risks of the use of Facilities and participation in Programs. I agree that I have full knowledge of the nature and extent of all such risks and am not relying on all such risks being described in this document.

Waiver, Release, Indemnification & Covenant Not to Sue
In consideration of Minor’s use of Facilities and participation in Programs I, in my legal capacity as parent/guardian of Minor, agree on behalf of myself and Minor that GREATER WATERBURY YMCA, its officers, directors, agents, employees, volunteers, insurers and representatives (“Releasees”) will not be liable for any personal injury, property damage, disability, death, sickness or disease incurred by Minor, however occurring including, but not limited to, the negligence of Releasees. I understand that Minor and I will be solely responsible for any loss or damage, including personal injury, property damage, disability, death, sickness, or disease sustained from the use of Facilities and participation in Programs.

I further agree, in my legal capacity as the parent/guardian of Minor, on behalf of Minor, myself, and any and all legal successors and proxies, to release and HEREBY DO RELEASE, WAIVE AND COVENANT NOT TO SUE Releasees from any causes of action, claims, suits, liabilities or demands of any nature whatsoever including, but in no way limited to, claims of negligence, which Minor, myself, and any and all legal successors and proxies may have, now or in the future, against Releasees on account of personal injury, property damage, disability, death, sickness, disease or accident of any kind, arising out of or in any way related to the use of Facilities or participation in Programs, whether that participation is supervised or unsupervised, however the injury or damage occurs, including, but not limited to, the negligence of Releasees.

In further consideration of the use of Facilities and participation in Programs, I, in my legal capacity as parent/guardian of Minor, agree on behalf of myself and Minor to INDEMNIFY AND HOLD HARMLESS Releasees from any and all causes of action, claims, demands, losses, suits, liabilities or costs of any nature whatsoever, including claims of negligence, arising out of or in any way related to the use of Facilities and participation in Programs.