Caring Honesty Responsibility Respect
 
Cost: (Y Guides/Y Princesses grades K-4)
Community Participants $70. Per father/child $40. each additional child
Discount for YMCA Members $35. per father/child $20. each additional child
     
Cost: (Trailblazers-grades 5 and up)
Community Participants $45. per father/child $20.each additional child
Discount for YMCA Members $25. per father/child $15. each additional child
Weekend events will be a separate charge. Please make checks payable to: Heritage YMCA Group

Registration Form

Father's Information

*First Name:      *Last Name:  
*Address: 
*City:    *State:    *Zip: 
*Subdivision:
*Home Phone:    Cell Phone:
*Father's Birth Date (mm/dd/yyyy): 
*Email: 

*Number of Children being registered:   
Please fill in the information below for each child being registered:

Child(ren) Information

*Child #1 Full Name:    *Birth Date (mm/dd/yyyy): 
*School:
*New or Returning Participant: 
*Select Program for this child:
*Preferred Tribe for this child:

Child #2 Full Name:   Birth Date (mm/dd/yyyy):
School:
New or Returning Participant:   
Select Program for this child:
Preferred Tribe for this child:

Child #3 Full Name:   Birth Date (mm/dd/yyyy):
School:
New or Returning Participant:   
Select Program for this child:
Preferred Tribe for this child:

Child #4 Full Name:   Birth Date (mm/dd/yyyy):
School:
New or Returning Participant:   
Select Program for this child:
Preferred Tribe for this child:

*How did you learn about our program?

Payment

*Payment Method: 

Consent Agreement

Participant or guardian assumes all risks of injury arising out of his or her presence on or about the premises or at another location, use or intended use of equipment and facilities, or his or her participation in the activities of the Heritage YMCA Group, an Illinois chartered not for profit corpora­tion and does hereby for himself, herself, heirs, executors and administrators waive, release, and agree to hold free from all claims for damages the Heritage YMCA Group, and its respective officers, directors, Trustees, Board of Directors, members, employees, or agents. I hereby allow the YMCA to take pictures (still or video) of myself and/or my children and grant permission for these images to be used in YMCA publications, presentations, publicity, or promotions. I have answered all above questions accurately, declare myself/family to be physically sound, having medical approval to engage in YMCA activities, have read the information above agreeing for myself and as a chosen representative for my family to the policies and procedures of the Heritage YMCA Group.

*Please read the Consent Agreement above and enter "yes" if you agree.
               Note: Agreement is required to register.
*Please enter your full name as "signature" to the Consent Agreement: 

Pals Forever…Friends Always        

 

For more information or registration details, please contact or email Russell Clarke at 630-585-2207