GYC Registration Form - City of Gaithersburg

$15 Resident
$18 Non-Resident
Olde Towne and Robertson Park
Join the GYC today or renew your GYC membership!
The primary Youth Center I attend is:
The Olde Towne Youth Center □
The Robertson Park Youth Center □
GYC Membership is good for 1 year!
INCLUDES ADMISSION TO YOUTH CENTERS & DISCOUNTS ON TRIPS
2013-2014 School Year
Questions? Call Rachel Tailby or Maura Dinwiddie at 301-258-6350
GYC MEMBER’S INFORMATION
REGISTRATION FORM
The school I attend is:
LPMS □ FOMS □
GMS □ RMS □
Other______________
First Name:___________________________________ Last Name:____________________________________________ M □ F □
Date of Birth:______________________________________________ Age:___________ Grade: ____________
PARENT/GUARDIAN INFORMATION □ Check here if new address/phone since last time registered.
First Name:____________________________________ Last Name:_____________________________________________ M □ F □
Address:__________________________________________________________________________________Apt #:_________
City/State:___________________________________________________________________ Zip Code:______________
Home Phone:_________________________ Work Phone:__________________________ City Resident □ Nonresident □
New! We can now email you GYC information on trips and special events:
Email Address:_________________________________________________________________________________________
The City of Gaithersburg is committed to making reasonable accommodations as required by the Americans with Disabilities Act. Requests
must be made prior to the start of the program. Please call 301-258-6350 to indicate what accommodations are needed.
I hereby grant permission for me/my child to attend the activity sponsored by the City of Gaithersburg. I understand that I am responsible for me/my
child’s insurance in case of injury. Furthermore, I understand that although safety precautions will be observed, the City of Gaithersburg, employees,
and agents will not be responsible for any personal property lost by me/my child or for any injury sustained in the program. I also consent to the City’s
use of any photographs and/or video tapes made of the program. In addition, I authorize my child to attend the off-site field trips and activities within
Gaithersburg associated with the GYC's programs. Trips will be posted in the monthly calendar.
_______________________________________________ _____________________________________________
Print Parent/Guardian Name Signature of Parent/Guardian
Amount Paid $ _____________ Cash □ Check # ____________
Visa/MC# __________________________________________ Exp. Date ___/___
Signature (name on card) ______________________________________________
Print Name___________________________________________________________
**** SEE REVERSE SIDE****
Office Use Only:
Rec’d:_________ Initials _______
W P M F Resident: Y N
Pr: ___________ Date:__________

CITY OF GAITHERSBURG
LIABILITY WAIVER FOR ROBERTSON PARK GYC ROCK-CLIMBING WALL
I know, understand, and acknowledge that there are risks associated with the use of City buildings/equipment/personal property and
hereby assume any and all risks and hazards associated therewith, and shall be solely responsible for safe and reasonable use.
I hereby irrevocably waive any and all claims against the City of Gaithersburg or any of its officials, employees, or agents for any bodily
injury (including death), loss or property damage incurred as a result of using the buildings/equipment/personal property and hereby
irrevocably release and discharge the City and any of its officials, employees, or agents from any and all claims of liability arising out of
or associated with the use of the buildings/equipment/personal property.
I shall indemnify and hold harmless the City and its officials, employees, and agents from and against any and all liabilities, judgements,
settlements, losses, costs, or charges (including attorney’s fees) incurred by the City or any of its officials, employees or agents as a result
of any claim, demand, action, or suit relating to any bodily injury (including death), loss or property damage caused by, arising out
of, related to or associated with the use of the buildings/equipment/personal property by its members, employees, agents, or invitees.
Liability waivers MUST be signed by the parent or guardian of each participant under the age of 18. Parents may NOT sign for
another person’s child. Any participant without a permission slip will not be allowed to use the Rock-Climbing Wall.
The City of Gaithersburg transfers all risk to _____________________________. ____________
Print Participant’s Name Date
Participant or Parent Signature (if under 18) Print Name (Parent/Guardian if under 18)
GYC Rules and Character Agreement
Respect … Be respectful of staff and all GYC members!
Listen and follow the directions of ALL GYC staff. Resolve disagreements with others respectfully or ask staff for help.
No shouting indoors- Noise must remain at a level that is comfortable for everyone.
RESPECT YOURSELF- NO DRUGS, ALCOHOL, TOBACCO OR WEAPONS ON YOUTH CENTER PROPERTY. THIS IS
MEANS FOR IMMEDIATE SUSPENSION.
Trustworthiness … Be trustworthy. Stealing or vandalism will not be tolerated.
Keep your hands off of other people’s property. Stealing is means for suspension.
Respect all GYC property and equipment. Vandalism is means for suspension.
If you break something or find something broken, report it immediately. You may be responsible for the replacement or repair
cost if you are at fault.
Citizenship …Be a good citizen. Do your part to make the Youth Center a safe & clean environment.
Throw away your trash! Even if it’s not your mess, help each other out!
Help clean up any activity you participate in. If you use it, put it back.
Do not climb or sit on game tables or any other furniture. Keep your feet on the ground.
NO RUNNING OR BOUNCING/THROWING BALLS INSIDE THE YOUTH CENTER.
NO EATING OR DRINKING on or around game tables, video games & computers.
Responsibility …The Youth Center is not responsible for any lost or stolen personal items- YOU ARE.
Lock up your bikes!
Keep your backpacks and personal items in a cubby. Security cameras are watching the cubby area at all times.
LOST GYC CARDS: $5.00 replacement fee. Forget your card for the day? You get one freebie…then, we charge $1/day.
Caring…Be kind. Inappropriate behavior towards others will not be tolerated.
Fighting, pushing and rough-housing are not allowed. Keep your hands to yourself!
Inappropriate language, harmful gossip and bullying will not be tolerated & are means for suspension.
Fairness … Playing fair is FUN.
Decide on the rules before you play the game- everyone must agree before you start!
Share games, supplies, & equipment. TAKE TURNS.
I agree to follow the procedures and rules outlined above. I understand
that failure to comply with them will result in appropriate disciplinary action.
Participant Signature _______________________________________ Date____________