Registration Form - Youth Programs

*Participants
First and Last
Name

Grade Fall 2013

School Attending

Age *

Date of Birth *

Gender

Use the field below to request that your child be assigned to a
particular team or instructor or to tell us anything else you
think we should know about your child i.e. bee sting allergy,
special medical or health concerns, etc.
(Please note: we do not guarantee special requests will be met.)

Requests or
Medical/Health
Concerns

(T-shirts only offered
with some programs.
Sizes run small.)

Best Contact Phone # *

Childs Mailing Address *

City *

Choose the Township
in which the child lives.
(NOT the same
as the County.) *

Assyria=Non-Resident Baltimore=Non-Resident
Barry TWP.=Non-Resident Carlton=Non-Resident
Castleton=Non-Resident City of Hastings=Resident
Hastings Charter=Non-Resident Hope=Non-Resident
Irving=Non-Resident Johnstown=Non-Resident
Maple Grove=Non-Resident Orangeville=Non-Resident
Priarieville=Non-Resident Rutland=Non-Resident
Thornapple=Non-Resident Woodland=Non-Resident
Yankee Springs=Non-Resident Outside of Barry County=Non-Resident

State *

Zip *

Does the address
above also belong to:

Both Parents Mother Only Father Only Other Guardian

Mother/Guardian
FIRST & LAST Name

Mother/Guardian Cell Phone

Father/Guardian
FIRST & LAST Name

Father/Guardian Cell Phone

HELP US GO GREEN!

By checking "yes" below your family will be put on a list to receive
newsletters & updates from the YMCA of Barry County via email
rather than through the US Postal Service.

*Receive
newsletters/updates
via email?

YesNoAlready Subscribe

Email Address

*Please Note*

We would contact the person listed below only in an emergency
after exhausting all other contact numbers listed above for the
parent/guardian.

Emergency Contact Name

Emerg. Contact Phone

Relation to Participant

**Please Note**

Some programs have different fees for residents and non-residents.
Currently Residents = City of Hastings.
The City of Hastings contracts with the YMCA to facilitate recreation
programs for its residents.

Thornapple-Kellogg
Swim Lessons

TK Summer Sess 3 - Pike - 9:00am - Mon & Wed - July 8-24 - $45 (3MPA)
TK Summer Sess 3 - Minnow - 9:00am - Mon & Wed - July 8-24 - $45 (3MMN)
TK Summer Sess 3 - Fish - 9:00am - Mon & Wed - July 8-24 - $45 (3MFA)
TK Summer Sess 3 - Eel - 10:00am - Mon & Wed - July 8-24 - $45 (3MEA)
TK Summer Sess 3 - Ray - 10:00am - Mon & Wed - July 8-24 - $45 (3MRA)
TK Summer Sess 3 - Guppy - 10:00am - Mon & Wed - July 8-24 - $45 (3MGA)
TK Summer Sess 3 - Polliwog 1 - 11:00am - Mon & Wed - July 8-24 - $45 (3MPW1A)
TK Summer Sess 3 - Polliwog 2 - 11:00am - Mon & Wed - July 8-24 - $45 (3MPW2A)

TK Summer Sess 4 - Pike - 7:00pm - Tue & Thu - July 9-25 - $45 (4MPA)
TK Summer Sess 4 - Polliwog 1 - 7:00pm - Tue & Thu - July 9-25 - $45 (4MPW1A)
TK Summer Sess 4 - Polliwog 2 - 7:00pm - Tue & Thu - July 9-25 - $45 (4MPW2A)
TK Summer Sess 4 - Guppy - 7:45pm - Tue & Thu - July 9-25 - $45 (4MGA)
TK Summer Sess 4 - Eel - 7:45pm - Tue & Thu - July 9-25 - $45 (4MEA)
TK Summer Sess 4 - Ray - 7:45pm - Tue & Thu - July 9-25 - $45 (4MRA)

Hastings - Pennock
Swim Lessons

Hastings Summer Sess 2 - Pike - 7:00pm - Tues & Thurs - July 16-Aug 1 - $45 (2HPA)
Hastings Summer Sess 2 - Polliwog 1 - 7:00pm - Tues & Thurs - July 16-Aug 1 - $45 (2HPW1A)
Hastings Summer Sess 2 - Polliwog 2 - 7:00pm - Tues & Thurs - July 16-Aug 1 - $45 (2HPW2A)

**Please Note**

Non-Residents are required to pay the fee for each week in which their child
participates in Playground and/or Tot Lot. If you choose to pay the fee online, you can
pay for multiple weeks all at once (remember the program
has 6 weeks available.)

Hastings Playground/Tot Lot

Hastings Playground - ALL 4 WEEKS - Ages 6 to 12 - City Resident FREE (HPGA)
Hastings Playground - ALL 4 WEEKS - Ages 6 to 12 - Non-City Resident PRE-PAY $60 (HPGA)

Hastings Playground - Week 1 - Central Elementary - Ages 6 to 12 - City Resident FREE (HPG1)
Hastings Playground - Week 1 - Central Elementary - Ages 6 to 12 - Non-City Resident $20 (HPG1)

Hastings Playground - Week 2 - Southeastern Elementary - Ages 6 to 12 - City Resident FREE (HPG2)
Hastings Playground - Week 2 - Southeatern Elementary - Ages 6 to 12 - Non-City Resident $20 (HPG2)

Hastings Playground - Week 3 - Bob King Park - Ages 6 to 12 - City Resident FREE (HPG3)
Hastings Playground - Week 3 - Bob King Park - Ages 6 to 12 - Non-City Resident $20 (HPG3)

Hastings Playground - Week 4 - Bob King Park - Ages 6 to 12 - City Resident FREE (HPG4)
Hastings Playground - Week 4 - Bob King Park - Ages 6 to 12 - Non-City Resident $20 (HPG4)

Hastings Tot Lot - ALL 4 WEEKS - Ages 3 to 5 - City Resident FREE (HTLA)
Hastings Tot Lot - ALL 4 WEEKS - Ages 3 to 5 - Non-City Resident PRE-PAY $60 (HTLA)

Hastings Tot Lot - Week 1 - Central Elementary - Ages 3 to 5 - City Resident FREE (HTL1)
Hastings Tot Lot - Week 1 - Central Elementary - Ages 3 to 5 - Non-City Resident $20 (HTL1)

Hastings Tot Lot - Week 2 - Southeastern Elementary - Ages 3 to 5 - City Resident FREE (HTL2)
Hastings Tot Lot - Week 2 - Southeatern Elementary - Ages 3 to 5 - Non-City Resident $20 (HTL2)

Hastings Tot Lot - Week 3 - Bob King Park - Ages 3 to 5 - City Resident FREE (HTL3)
Hastings Tot Lot - Week 3 - Bob King Park - Ages 3 to 5 - Non-City Resident $20 (HTL3)

Hastings Tot Lot - Week 4 - Bob King Park - Ages 3 to 5 - City Resident FREE (HTL4)
Hastings Tot Lot - Week 4 - Bob King Park - Ages 3 to 5 - Non-City Resident $20 (HTL4)

Middleville Playground

Middleville Playground - Week 1 - Village Resident - Ages 6 to 12 - Free (MPG)
Middleville Playground - Week 1 - Non-Village Resident - Ages 6 to 12 - $20 (MPG)

Exploremore Program 5th-8th Grades

Exploremore - 2 Weeks - June 17-20 & Aug 5-8 - 5th-8th Grades - $150 (EXP)

Summer Floor Hockey Clinic

Ages 7-9 - Floor Hockey Clinic - 9:00am - $10.00 (SFH7-9)
Ages 10-12 - Floor Hockey Clinic - 10:15am - $10.00 (SFH10-12)

**PLEASE NOTE**

IF REGISTERING LESS THAN 1 WEEK BEFORE THE PROGRAM
DEADLINE PLEASE DO NOT SEND YOUR PAYMENT BY MAIL!
Thank you!

Pay Online

Yes, by checking this box I agree to pay online. After clicking
submit, you will be taken to a page with a link to pay with PayPal.
Clicking that link will give you the option to use an "Add to Cart"
button to pay for one or multiple registration fees.

If you are NOT
paying online,
please choose
another payment
method:

I Will Pay by Visa MC or Discover over the Phone
I Will Place my Payment in a Drop Box
I Will Mail My Check Or Money Order
I Will Pay At The YMCA Office
I Have Financial Aid
I Will Apply for Financial Aid The Program Chosen is Free of Charge

Agreement *

Yes, I agree to the best of my knowledge, the information
given above is accurate and complete. By
checking this box, I hereby give my
permission for my child to participate in
YMCA of Barry County programs. I assume all
risks and hazards incidental to such
participation, including transportation to and
from activities. I give my permission for the
coach, league official or YMCA staff to
take my child for emergency care in case of
sudden emergency or if I cannot be reached at
that time. I do hereby waive, release,
absolve, indemnify, and agree to hold
harmless the YMCA of Barry County, and/or
organizers, sponsors, supervisors, participants
and persons transporting my child from
activities. I also hereby give my permission
to use photos, videotapes or any other media
record of my childs participation for any
lawful purposes.

Send My Registration

**WARNING**

After clicking submit, the next screen will say
THANK YOU at the top. If you do not see
the THANK YOU screen your registration
has not been submitted properly. This may
be due to certain manditory fields left blank. If so,
you will see a notice in red under the field(s)
in which information is missing. Fill in any
missing information and click submit again. Thanks.