Complimentary Swim Access Lesson Interest Form: Feb-Apr '22

Complimentary Swim Lesson Interest Form
Session Dates: February 7-April 3, 2022

Please complete the interest form below. You will be contacted 1-2 weeks prior to the start of the session to finalize enrollment and confirming the day and time the program will be offered.

Classes are offered by age group. We offer a preschool swim access program for children ages 3-5 years old. The youth swim access program is for youth ages 5-12 years old.
Parent/Guardian Name *

First Name Last Name
Birthdate *

Month Day Year
Date
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Phone Number *
Please enter a valid phone number.
Email *
example@example.com
Name of Referring Organization *

River Forest Library Oak Park River Forest Community Foundation School District 89 School District 90 Other

Permissions and Authorizations
Photo/Video Permission Authorization *

I give permission for my child to have their picture and/or video taken as part of the West Cook YMCA Program. I understand that the picture or video may be used for West Cook YMCA marketing and communications including but not limited to using within the facility, newspapers, or other media outlets I DO NOT give permission for my child to have their picture and/or video taken for the purpose of West Cook YMCA marketing and communications including but not limited to using within the facility, newspapers, or other media outlets
Hold Harmless Indemnification Authorization *

I agree that the West Cook YMCA shall not be responsible for any personal injuries or losses sustained by me/my child while on any YMCA premises or as a result of YMCA sponsored activities. I further agree to idemnify and hold harmless the West Cook YMCA from any claims or demands arising out of any such injuries or losses. If I am asked, I also agree to leave the facility due to inappropriate behavior as defined by the YMCA staff. A refund will not be given if asked to leave.
I give authorization based on the above marked boxes. *

Clear
Date of Signature *

Month Day Year
Date
Should be Empty:

Complimentary Swim Lesson Interest Form