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WELCOME! 

Thank you for visiting YMCA Silver Spring. Please sign the guest waiver and complete the information requested below. When complete, please provide your photo identification to the staff at the front desk. 

The mission of the YMCA of Metropolitan Washington is to foster the spiritual, mental and physical development of individuals, families and communities according to the ideals of inclusiveness, equality and mutual respect for all.

Today's date:  May 21, 2024

 

RELEASE OF LIABILITY - GUEST WAIVER FORM

I expressly acknowledge that there are certain dangers, risks, illnesses, personal injuries and death inherent in attending and/or participating in the YMCA's programs, events, classes, and any other activities (including, but not limited to individual exercise, strength training, group exercise, sports, challenges, competitions, horseback riding, self-defense, archery, field trips, waterfront and pool activities, canoeing/boating, campfires, hiking, high ropes and other challenge courses) at and/or sponsored by the YMCA, which may result from falls, accidents or injuries, negligence of any person or organization, my participation in the programs, events, classes and any other activities, the update of any facilities and equipment, exercise, or from my or my minor child(ren)'s or war(s)' physical condition (collectively, the "Activities"). I understand that the YMCA, and it's employees, agents, counselors, teachers, trainers, representatives, successors and assigns (collectively "Released Parties") assume no responsibility for loss, damage, illness, injury, or death to person or property that I or my minor child(ren) and ward(s), if applicable, may sustain arising out of, resulting from or in any way connected with the Activities, including by reason of the active or passive negligence of any of the Released Parties. I expressly acknowledge, on behalf of myself and my minor child(ren) and ward(s), heirs and executors, that I voluntarily assume the sole risk for any and all losses, damages, illnesses, personal injuries or death that may result from my or my minor child(ren)s’ or ward(s) Activities at and/or sponsored by the YMCA. In consideration of the Released Parties allowing me and/or my minor child(ren) or ward(s) to attend and/or participate in the Activities, I hereby, for myself, my minor child(ren) or ward(s), heirs and executors, waive, release, and forever discharge the Released Parties from and against any and all rights and claims for any loss, damage, illness, injuries or death to person or property sustained arising out of, resulting from or in any way connected with the Activities, whether or not such loss, damage, illness, injury or death results from the negligence of the Released Parties or from some other cause. I also acknowledge that the Released Parties may use photographs, videotapes, television programs, motion pictures, tape recordings, or other similar media pertaining to the Activities for promotional purposes. I hereby consent to the use of my and/or my minor child(ren) or ward(s)’ name(s) and/or likeness(es) in such materials to be exhibited and used for advertising, trade purposes, sociation of patronage, promotional purposes or other similar purposes, even if my and/or my minor child(ren)’s or ward(s)’ name(s) and/or likeness(es) are an integral part of such photograph, videotape, television programs, motion picture, tape recording, or other similar media. I further waive any and all rights to inspect or approve the photograph, videotape, television program, motion picture, tape recording or other use of my and/or my minor child(ren)’s or ward(s)’ name(s) and/or likeness(es), including any written article, script, caption, or other writing that may accompany such use of my and/or my minor child(ren)’s or ward(s)’  name(s) and/or likeness(es). I hereby, for myself for myself, my minor child(ren) or ward(s), heirs and executors, waive, release, and forever discharge the Released Parties from and against any and all liability, claims, losses, costs expenses or damages from libel, slander, invasion of privacy, conversation, defamation, appropriation of likeness or any other claim based on the use of for myself, my minor child(ren) or ward(s) name(s) and/or likeness(es) in any such material. I hereby represent and warrant to the Released Parties that I have the authority to execute this Participant Waiver Form on behalf of myself and/or on behalf of my minor child(ren) or ward(s) as parent, guardian and/or next friend, if applicable, in the event of any misrepresentations or breach of the foregoing warranty by me, or in the event that I, my minor child(ren) or ward(s) or any other person nevertheless asserts any claim against the Released Parties arising out of my minor child(ren)’s or ward(s)’ attendance or participation in the Activities as set forth herein, I agree to indemnify, hold harmless and defend the Released Parties from and against any and all liability, claims, loss, costs, expense or damages arising there from, including, but not limited to, claims of loss, damage, illness, injury or death to person or property whether or not such loss, damage, injury or death results from the negligence of the Released Parties or from some other cause.

I have read the Terms and Conditions agreement.

I Agree

COVID-19

Coronavirus, COVID-19, is an extremely contagious virus that spreads easily through person-to-person contact. An inherent risk of exposure to COVID-19 exists in any public place where people are present. Federal and state authorities recommend social distancing as a means to prevent the spread of the virus. COVID-19 can lead to severe illness, personal injury, reproductive harm, permanent disability, and death. According to the Centers for Disease Control and Prevention, senior citizens and persons with underlying medical conditions are especially vulnerable. You acknowledge that participating in or observing YMCA programs, events, classes, and other activities, or even merely accessing YMCA facilities, may increase the risk of contracting COVID-19 or other infectious diseases. The YMCA in no way warrants that COVID-19 infection or other infectious diseases will not occur through participation in or observation of YMCA programs, events, classes, and other activities or accessing YMCA facilities. By participating in or observation of YMCA programs, events, classes and other activities, or accessing YMCA facilities, you voluntarily assume all risks associated with exposure to COVID-19. The YMCA will not be liable for any claims associated with, any illness, personal injury, disability or death associated with COVID-19, even if it can be established that you or your child(ren) or dependent(s) contracted an infection through participation in YMCA programs, events, classes, and other activities or accessing YMCA facilities. Anyone exhibiting symptoms of COVID-19 or who was recently exposed to COVID-19 within the preceding 14-day period must refrain from participating or observing, in any YMCA programs, events, classes, and other activities, or access YMCA facilities.

I Agree

First Guest Name

First Name*

Last Name*

Phone*
First Guest Date of Birth*
First Guest Information

Gender Identification *
The main reason I visited today*

If Other, please explain
As a member at the Y, I would like to
Meet new people and make new friends
Lead a healthy lifestyle
Spend time with friends and family
Reduce / relieve stress
Reduce risk of chronic disease
Rehabilitate from an injury / illness
Achieve a different specific goal

If you have a different specific goal, please explain
I am interested in (please check all that apply)... *
Using fitness equipment
Participating in group exercise classes
Attending educational seminars
Participating in cooking / nutrition classes
YMCA programs for me / my family
Social activities
Sports leagues
Summer camps
Pickleball
Swimming
Tennis
Donating to the YMCA
Volunteering
Other
First Guest Signature*
Second Guest Name

First Name*

Last Name*
Second Guest Date of Birth*
Second Guest Information

Gender Identification *
The main reason I visited today*

If Other, please explain
As a member at the Y, I would like to
Meet new people and make new friends
Lead a healthy lifestyle
Spend time with friends and family
Reduce / relieve stress
Reduce risk of chronic disease
Rehabilitate from an injury / illness
Achieve a different specific goal

If you have a different specific goal, please explain
I am interested in (please check all that apply)... *
Using fitness equipment
Participating in group exercise classes
Attending educational seminars
Participating in cooking / nutrition classes
YMCA programs for me / my family
Social activities
Sports leagues
Summer camps
Pickleball
Swimming
Tennis
Donating to the YMCA
Volunteering
Other
Third Guest Name

First Name*

Last Name*
Third Guest Date of Birth*
Third Guest Information

Gender Identification *
The main reason I visited today*

If Other, please explain
As a member at the Y, I would like to
Meet new people and make new friends
Lead a healthy lifestyle
Spend time with friends and family
Reduce / relieve stress
Reduce risk of chronic disease
Rehabilitate from an injury / illness
Achieve a different specific goal

If you have a different specific goal, please explain
I am interested in (please check all that apply)... *
Using fitness equipment
Participating in group exercise classes
Attending educational seminars
Participating in cooking / nutrition classes
YMCA programs for me / my family
Social activities
Sports leagues
Summer camps
Pickleball
Swimming
Tennis
Donating to the YMCA
Volunteering
Other
Fourth Guest Name

First Name*

Last Name*
Fourth Guest Date of Birth*
Fourth Guest Information

Gender Identification *
The main reason I visited today*

If Other, please explain
As a member at the Y, I would like to
Meet new people and make new friends
Lead a healthy lifestyle
Spend time with friends and family
Reduce / relieve stress
Reduce risk of chronic disease
Rehabilitate from an injury / illness
Achieve a different specific goal

If you have a different specific goal, please explain
I am interested in (please check all that apply)... *
Using fitness equipment
Participating in group exercise classes
Attending educational seminars
Participating in cooking / nutrition classes
YMCA programs for me / my family
Social activities
Sports leagues
Summer camps
Pickleball
Swimming
Tennis
Donating to the YMCA
Volunteering
Other
Fifth Guest Name

First Name*

Last Name*
Fifth Guest Date of Birth*
Fifth Guest Information

Gender Identification *
The main reason I visited today*

If Other, please explain
As a member at the Y, I would like to
Meet new people and make new friends
Lead a healthy lifestyle
Spend time with friends and family
Reduce / relieve stress
Reduce risk of chronic disease
Rehabilitate from an injury / illness
Achieve a different specific goal

If you have a different specific goal, please explain
I am interested in (please check all that apply)... *
Using fitness equipment
Participating in group exercise classes
Attending educational seminars
Participating in cooking / nutrition classes
YMCA programs for me / my family
Social activities
Sports leagues
Summer camps
Pickleball
Swimming
Tennis
Donating to the YMCA
Volunteering
Other
Sixth Guest Name

First Name*

Last Name*
Sixth Guest Date of Birth*
Sixth Guest Information

Gender Identification *
The main reason I visited today*

If Other, please explain
As a member at the Y, I would like to
Meet new people and make new friends
Lead a healthy lifestyle
Spend time with friends and family
Reduce / relieve stress
Reduce risk of chronic disease
Rehabilitate from an injury / illness
Achieve a different specific goal

If you have a different specific goal, please explain
I am interested in (please check all that apply)... *
Using fitness equipment
Participating in group exercise classes
Attending educational seminars
Participating in cooking / nutrition classes
YMCA programs for me / my family
Social activities
Sports leagues
Summer camps
Pickleball
Swimming
Tennis
Donating to the YMCA
Volunteering
Other
Seventh Guest Name

First Name*

Last Name*
Seventh Guest Date of Birth*
Seventh Guest Information

Gender Identification *
The main reason I visited today*

If Other, please explain
As a member at the Y, I would like to
Meet new people and make new friends
Lead a healthy lifestyle
Spend time with friends and family
Reduce / relieve stress
Reduce risk of chronic disease
Rehabilitate from an injury / illness
Achieve a different specific goal

If you have a different specific goal, please explain
I am interested in (please check all that apply)... *
Using fitness equipment
Participating in group exercise classes
Attending educational seminars
Participating in cooking / nutrition classes
YMCA programs for me / my family
Social activities
Sports leagues
Summer camps
Pickleball
Swimming
Tennis
Donating to the YMCA
Volunteering
Other
Eighth Guest Name

First Name*

Last Name*
Eighth Guest Date of Birth*
Eighth Guest Information

Gender Identification *
The main reason I visited today*

If Other, please explain
As a member at the Y, I would like to
Meet new people and make new friends
Lead a healthy lifestyle
Spend time with friends and family
Reduce / relieve stress
Reduce risk of chronic disease
Rehabilitate from an injury / illness
Achieve a different specific goal

If you have a different specific goal, please explain
I am interested in (please check all that apply)... *
Using fitness equipment
Participating in group exercise classes
Attending educational seminars
Participating in cooking / nutrition classes
YMCA programs for me / my family
Social activities
Sports leagues
Summer camps
Pickleball
Swimming
Tennis
Donating to the YMCA
Volunteering
Other
Ninth Guest Name

First Name*

Last Name*
Ninth Guest Date of Birth*
Ninth Guest Information

Gender Identification *
The main reason I visited today*

If Other, please explain
As a member at the Y, I would like to
Meet new people and make new friends
Lead a healthy lifestyle
Spend time with friends and family
Reduce / relieve stress
Reduce risk of chronic disease
Rehabilitate from an injury / illness
Achieve a different specific goal

If you have a different specific goal, please explain
I am interested in (please check all that apply)... *
Using fitness equipment
Participating in group exercise classes
Attending educational seminars
Participating in cooking / nutrition classes
YMCA programs for me / my family
Social activities
Sports leagues
Summer camps
Pickleball
Swimming
Tennis
Donating to the YMCA
Volunteering
Other
Tenth Guest Name

First Name*

Last Name*
Tenth Guest Date of Birth*
Tenth Guest Information

Gender Identification *
The main reason I visited today*

If Other, please explain
As a member at the Y, I would like to
Meet new people and make new friends
Lead a healthy lifestyle
Spend time with friends and family
Reduce / relieve stress
Reduce risk of chronic disease
Rehabilitate from an injury / illness
Achieve a different specific goal

If you have a different specific goal, please explain
I am interested in (please check all that apply)... *
Using fitness equipment
Participating in group exercise classes
Attending educational seminars
Participating in cooking / nutrition classes
YMCA programs for me / my family
Social activities
Sports leagues
Summer camps
Pickleball
Swimming
Tennis
Donating to the YMCA
Volunteering
Other
Guest Address
Address Line 1:*
Street address, P.O. box, company name, c/o
Address Line 2:
Apartment, suite, unit, building, floor, etc.
Country:*
City:*
State/Province:*
Zip/Postal:*
Parent or Guardian's Email Address

Email
A signed copy of this waiver will be sent to the email address you provide.
Emergency Contact

First Name*

Last Name*

Emergency Contact's Phone Number*
Parent(s) or court-appointed legal guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.


By signing below the parent or court-appointed legal guardian agrees that they are also subject to all the terms of this document, as set forth above.
Parent or Guardian's Name

First Name*

Last Name*

Phone*
Parent or Guardian's Date of Birth*
Parent or Guardian's Information

Gender Identification *
The main reason I visited today*

If Other, please explain
As a member at the Y, I would like to
Meet new people and make new friends
Lead a healthy lifestyle
Spend time with friends and family
Reduce / relieve stress
Reduce risk of chronic disease
Rehabilitate from an injury / illness
Achieve a different specific goal

If you have a different specific goal, please explain
I am interested in (please check all that apply)... *
Using fitness equipment
Participating in group exercise classes
Attending educational seminars
Participating in cooking / nutrition classes
YMCA programs for me / my family
Social activities
Sports leagues
Summer camps
Pickleball
Swimming
Tennis
Donating to the YMCA
Volunteering
Other
Parent or Guardian's Signature*
Electronic Signature Consent*
By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


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