Membership Registration

* required information
Registration 
Registration Information
First Name:*
Last Name:*
Email:*
Address Line 1:*
Address Line 2:
City:*
State:*
ZIP/Postal Code:*
Country:*
Phone:*
Birth Date:*(mm/dd/yyyy)
Gender:* Female   Male  
How did you hear about us?:
Ethnicity:*
Fees
Child (under 12 years old)
$25.00
Senior (65+)
$30.00
Adult (12-64 years old)
$35.00
Contributor
(Indicates a donor member who gives above and beyond the basic membership level as a donation to YWCA York.)
$50.00
Supporter
(Indicates a donor member who gives above and beyond the basic membership level as a donation to YWCA York.)
$75.00
Sustainer
(Indicates a donor member who gives above and beyond the basic membership level as a donation to YWCA York.)
$100.00
Benefactor
(Indicates a donor member who gives above and beyond the basic membership level as a donation to YWCA York.)
$250.00
Donation
Amount:$
Additional Information
Type of Membership:* New
Renewal
Please read and agree to the following waiver. Parent or Gaurdian, please agree for children under the age of 18 years of age. In the event I register and/or participate in any YWCA programs, I agree to the following Release of Liability: 1. I understand and am aware that strength, flexibility, swimming and aerobic exercise, including the use of equipment, is a potentially hazardous activity. I also understand that fitness activities involve a risk of injury and even death and that I am voluntarily participating in these activities and using equipment and machinery with knowledge of the dangers involved. 2.I declare myself to be physically sound and suffering from no condition, impairment, disease, infirmity, or other illness that would prevent my participation or use of equipment or machinery except as stated. I acknowledge that I have been informed of the need for a physicianís approval for my participation in an exercise/fitness activity or in the use of exercise equipment and machinery. I acknowledge that I have either had a physical examination and been given my physicianís permission to participate, or that I have decided to participate in activity and use of equipment and machinery without the approval of my physician and that I assume all responsibility for my participation and activities. 3. I fully understand the nature of the YWCA programs and I waive and release any and all responsibilities, liability or damages which may be blamed upon such exercise and assistance. IMPORTANT: Please talk to your instructor before the first class if your child has any special conditions that we should be made aware of. By submitting this form I agree that all information was entered accurately and truthfully. I also agree to the Release of Liability.