Wyoming County YMCA Membership Application
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First Name *
Last Name *
Birthdate *
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Gender *
Home Street Address *
City *
Zip Code *
Primary Phone Number *
Email Address *
Place of Employment
**Employee of eligible companies will have their joining fee waived and will receive an additional discount off YMCA membership dues. Please bring in valid ID card for verification. Discount will be applied once this is done in person.
Civil Servant Position (Check any box that applies)
Emergency Contact First Name *
Emergency Contact Last Name *
Emergency Contact Phone Number *
YOUR CONSENT AND RELEASE
I hereby agree to release and hold harmless the YMCA, its employees and volunteers, from any loss, liability, claim of bodily injury or property damage, or costs which may arise due to my use of the YMCA’s facilities and equipment and my participation in YMCA programs. This agreement shall be governed by the laws of New York State.

I authorize the use and reproduction of any and all photographs or video footage for YMCA promotional purposes and I will not be compensated for this use.

I understand that conduct contrary to the YMCA core values of Caring, Honest, Respect and Responsibility, the intentional or unintentional disruption or preventing YMCA members’ ability to enjoy their membership or YMCA staff and/or volunteer’ ability to conduct class or their job duties, is not acceptable behavior and may result in the termination of my membership.

By signing this form, I agree that I have read this entire form and understand my responsibilities for participation and conduct in YMCA programs and activities.

The YMCA conducts regular sex offender screenings on all members, participants, and guests. If a sex offender match occurs, the YMCA reserves the right to cancel membership, end program participation, and remove visitation.

By typing my name in the space provided, this is my electronic signature validating my consent and release of the YMCA.
Electronic Signature (Type your Full Name) *
Today's Date *
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Type of Membership *
Membership Billing Cycle *
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