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Child Permission Form

Parents, please use this form to submit permission for your child to visit a Heart of the Valley YMCA branch. You are signing a waiver and providing medical authorization.

Child's Full Name*
Enter your child's first name and last name.
First Last
Child's Date of Birth
Branch to be Visited*
Select the branch where your child would like to visit.
- Downtown Express YMCA
- Hogan Family YMCA
- Southeast Family YMCA
Approved Adults Your Child May Accompany*
Please list the names of adults with whom you approve your child attending the YMCA. Your child must have a YMCA membership or be listed on the attending adult membership. PLEASE NOTE: Only adults ages 19 and up who are members of Heart of the Valley YMCA may bring your child to the YMCA.
Adult First Name Adult Last Name
Consent*
THIS IS A RELEASE. READ CAREFULLY BEFORE SIGNING.
I recognize that participation in YMCA activities may expose my child to some risk of injury. I agree to hold the YMCA harmless from any claims for damage to any property or injury to persons which may occur through participation in any activity at the YMCA or its programs. In case of an emergency or accident, and I am unable to be contacted, I hereby grant the YMCA director, or his or her agent to secure proper medical treatment and transportation for my child to an appropriate facility for treatment. I understand the YMCA has a code of conduct, and I agree to abide by that conduct. I give the Heart of the Valley YMCA permission to use photos of my child/family/ward for use in their brochures, program promotions and other YMCA presentations. I have read and understand the above information. My child has permission to participate in YMCA activities in accordance with the conditions set forth above. This form is valid for one day’s visit only, and my child is subject to the Heart of the Valley YMCA Guest Policy.

MEDICAL AUTHORIZATION
In the event of an emergency, I hereby authorize and give permission to any physician, hospital, or other healthcare provider as may be designated by the YMCA, at its discretion, to transport, treat, hospitalize, and provide emergency medical treatment for, and to order, authorize and administer injection(s), anesthesia or surgery for all persons named on this application.
I agree to the Heart of the Valley YMCA Minor Guest Policy
Parent/Guardian Name*
Please print the parent or legal guardian name.
First Last
Parent/Guardian Email*
Phone Number*
Driver's License*
Upload a copy of the Parent/Guardian driver's license.
Accepted file types: jpg, pdf, png, gif, heic, jpeg, Max. file size: 20 MB.

Adult First Name	Adult Last Name