SCHOOL STAFF ENROLLMENT FORM

2013 YMCA BLUE RIDGE LEADERS’ SCHOOL

ONLY TYPED FORMS WILL BE ACCEPTED

TYPE INTO FIELDS BELOW, PRINT AND SEND TO ANGIE MILLER AT THE ADDRESS BELOW

Date of Birth: / Age (as of May 31): / Female Male
Name: / Cell Phone:
Address:
City: / State: / Zip:
YMCA Name:
Email Address:
This is my year at Blue Ridge Leaders' School.
T-Shirt Size: S M L XL XXL

In consideration of the acceptance of this enrollment I hereby waive, release and forever discharge YMCA Blue Ridge Leaders’ School, YMCA Blue Ridge Assembly, the YMCA and their respective staff members, employees and representatives from any and all claims, liabilities, damages and/or related expenses resulting from or related to my participation in Leaders’ School activities. I understand that YMCA Blue Ridge Leaders’ School does not carry accident insurance on the participants. I agree that YMCA Blue Ridge Leaders’ School may photograph or videotape me and may use those photographs and videotapes for its marketing purposes and I release YMCA Blue Ridge Leaders’ School from any claim or liability related to that use and waive all claims for myself, my heirs and assignees against YMCA Blue Ridge Leaders’ School.

Staff Member Signature Date

If your spouse and/or children will be attending with you please list their name and age below:

Name: / Age: / Family Rates:
Spouse $400
Child (3-12 yrs) $225
Name: / Age:
Name: / Age:

Please return this form and the $60 staff fee (for full-time staff) to: Angie Miller

Hampton Family YMCA

1322 LaSalle Avenue

Hampton, VA 23669

FAX: (757) 722-3556

Email:

* * * * * * * * * Blue Ridge Office Use Only * * * * * * * * * *

Date Received Amount Paid $ Amount Due $

Room #

Page 1 of 1 Staff Enrollment Form