GUEST PASS APPLICATION
YMCA OF PIERCE AND KITSAP COUNTIES
FACILITY Association Office | 1614 S Mildred St Ste 1 | Tacoma WA 98465
GUEST UNIT NO.
Bremerton AWAY GUEST
YMCA BRANCH: VERIFIED BY:
Haselwood
Lakewood
Mel Korum
Morgan
Tacoma Center
Tom Taylor
DATE: MEMBER UNIT NO. M.I. LAST NAME SEX
ADULT GUEST (PLEASE PRINT) GUEST OF (PLEASE PRINT MEMBERS NAME)
GUEST FIRST NAME GUEST STREET ADDRESS CITY GUEST PRIMARY PHONE (INCLUDING AREA CODE) EMERGENCY PHONE (INCLUDING AREA CODE)
Male
Female
STATE BIRTH DATE (MM/DD/YYYY) GUEST DRIVERS LICENSE NO.
ZIP AGE STATE
YOUTH GUEST FIRST NAME
YOUTH GUEST UNDER AGE 18 (PLEASE PRINT)
M.I.
LAST NAME
SEX
Male
YOUTH GUEST STREET ADDRESS CITY YOUTH GUEST PRIMARY PHONE (INCLUDING AREA CODE) YOUTH GUEST PARENT/GUARDIAN FULL NAME PLEASE CHECK ONE STATE BIRTH DATE (MM/DD/YYYY) PARENT/GUARDIAN BIRTH DATE ZIP AGE AGE
Female
GUEST OF (PLEASE PRINT ADULT MEMBERS NAME)
Mother
Father
Guardian
CONDITIONS OF GUEST USE OF THE YMCA
Guest Health: Guest represents they are in physically sound condition and understands that participation in cardio exercise, weight training, recreational sports, and the use of pools, spas, saunas, steam rooms, and fitness equipment carry a potential risk of injury or illness. The guest understands the YMCA of Pierce and Kitsap Counties (the Y) assumes no responsibility for any such injury or illness. Guest Conduct and Use of Facility: Guest agrees to abide by all policies and practices of the Y and its branches and facilities, and understands failure to act in accordance with these rules may result in expulsion from the Y and revocation of the guess pass with no refund. Criminal History: Applicant acknowledges it is the policy of the Y to deny access to any individual registered as a Level 2 or Level 3 sex offender. Property Loss: Guest understands the Y is not responsible for personal property lost, damaged, or stolen while using YMCA facilities including parking lots or participating in YMCA programs. Photograph Permission: Guest hereby grants permission for the Y to use, without limitation or obligation, photographs or other media which may include the guests image or voice to promote or interpret YMCA programs. Insurance: Guest understands the Y does not provide any accident or health insurance for its guests, members, or participants, and further understands it is the guests responsibility to provide such coverage.
RELEASE AND WAIVER OF LIABILITY
I am aware that participation in YMCA programs and use of YMCA facilities may involve certain hazards associated with equipment, physical exertion, games, sports, and other programs/activities offered by the Y. In consideration of, and as part payment for, the right to use YMCA facilities and participate as a guest in YMCA programs, I will hold harmless and indemnify the Y (the Y includes its employees, volunteers, directors, officers, and agents) for damages of any type including permanent physical injuries or death, arising out of the ordinary negligence of the Y. This release includes indemnifying and forgoing any claim I may have for ordinary negligence arising out of my childrens use of the Ys facilities or participation in YMCA programs. I fully understand and agree I am waiving all claims I may have against the Y arising out of the ordinary negligent acts by the Y, and I agree I will not bring a lawsuit against the Y arising out of its ordinary negligence. If any portion of this release is held invalid, I agree the remainder shall continue to be enforceable. ADULT GUEST SIGNATURE DATE PARENT/GUARDIAN SIGNATURE (IF UNDER AGE 18) DATE
PLEASE CHECK APPROPRIATE METHOD OF PAYMENT
FOR OFFICE USE ONLY Cash Check
AMOUNT PAID
PHOTO TAKEN
ALERT ENTERED
Debit/Credit Card
$
STAFF INITIALS
Yes
Yes
NAME ON DEBIT/CREDIT CARD CHARGED PLEASE USE SEPARATE FORM FOR MULTIPLE HOUSEHOLDS
APPLICATION EXPIRATION DATE (MM/DD/YYYY)
