Titusville YMCA Lose2Win 2021 Registration
January 5 - March 16 (10 weeks)

YMCA Member Price = $25
YMCA Non-Member Price = $60
Please use PayPal, call the YMCA (814-827-3931), or stop by the YMCA to make a payment. Your registration is not complete until payment has been received.

For more details and benefits of the challenge, please see our website or Lose2Win Handout.

For questions, please call the YMCA at 814-827-3931, or email Jacquelyn Slater at jslater@titusvilleymca.org
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Participant Information
Last Name *
First Name *
Is the participant a current Titusville YMCA Member? *
Membership Info
Membership benefits include discounted program and class fees and member only programs.

YMCA Membership Rates can be found on our website: https://titusvilleymca.org/rates

Financial Assistance is available, more info on the website or you can stop by the Y.
Birthdate: *
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Age *
Gender *
Height (inches) *
Goal Weight for the End of the Challenge (3/16/21)
Secret Name
https://docs.google.com/document/d/1tsxrqiVe-ZAcUgjCdsZFsR9yDnE9LAmyILsFuVXZZtk/edit?usp=sharing

Go to the link above and you will see a list of fruits and vegetables.

One of those fruits or vegetables will be your "secret name" throughout the competition. This is how your results will be posted rather than posting your results under your actual name.

Below, enter your top three choices, and at least write down, or remember, your top choice.

Anything that is highlighted is already taken, so don't pick those. This list will be updated regularly.

If you don't hear from Jacquelyn regarding your secret name, you got your top choice. If you got your second or third choice, Jacquelyn will send you an email letting you know what your secret name is.
Secret Name - Top Choice *
Secret Name - Second Choice *
Secret Name - Third Choice *
T-Shirt Size *
Address: *
City *
State *
Zip Code *
Phone Number *
Email Address *
Allergies/Medical Condition(s): *
The Titusville YMCA carries secondary insurance on all participants with substantial deductibles and which requires the use of your own primary health insurance to pay first and to its limit and after the exhaustion of all other coverage for which the participant may be eligible plus applicable deductibles before any payment will be made. I understand that in lieu of a primary health or accident policy, I am required and will accept full financial responsibility for any injury myself or my child may incur while on Titusville YMCA premises or while participating in any activity at or sponsored by the Titusville YMCA. *
Required
Emergency Contact Information
Primary Emergency Contact Name: *
Primary Emergency Contact Phone Number: *
Relationship to Primary Emergency Contact: *
Secondary Emergency Contact Name: *
Secondary Emergency Contact Phone Number: *
Relationship to Secondary Emergency Contact: *
Medical Attention Release
I hereby release the Titusville YMCA staff to render temporary first aid in the event of an injury or illness, and if deemed necessary by the Titusville YMCA staff, to call 911 and seek medical help, or call an ambulance. *
Required
Photo/Video Release
I give permission to the Titusville YMCA to use photos/videos of me for news releases, promotions, and publications. *
Adult Participant Release & Waiver of Liability and Indemnity Agreement
PLEASE READ CAREFULLY. THIS DOCUMENT AFFECTS YOUR LEGAL RIGHTS AND IS LEGALLY BINDING. BY SIGNING THIS AGREEMENT YOU ARE RELEASING TITUSVILLE YMCA FROM ALL LIABILITY AND FOREVER GIVING UP ANY CLAIMS THEREFOR
Assumption of Risk
I acknowledge and agree that any use of Titusville YMCA facilities, services, equipment and premises (“Facilities”) and any participation in Titusville YMCA programs and activities (“Programs”) comes with inherent risks including, but in no way limited to: (1) moderate and severe personal injury, (2) property damage, (3) disability, (4) death, and (5) sickness or disease. I voluntarily accept and assume full responsibility for these risks as well as any and all other risks of the use of Facilities and participation in Programs. I agree that I have full knowledge of the nature and extent of all such risks and am not relying on all such risks being described in this document.
Waiver, Release, Indemnification & Covenant Not to Sue
In consideration of the use of Facilities and participation in Programs I, the undersigned, agree that Titusville YMCA, its officers, directors, agents, employees, volunteers, insurers and representatives (“Releasees”) will not be liable for any personal injury, property damage, disability, death, sickness or disease incurred by myself, my family members, dependents, or guests, including minors, however occurring including, but not limited to the negligence of Releasees. I understand that I will be solely responsible for any loss or damage, including personal injury, property damage, disability, death, sickness or disease sustained from the use of Facilities and participation in Programs.

I further agree, on behalf of myself and any and all legal successors and proxies, to release and HEREBY DO RELEASE, WAIVE AND COVENANT NOT TO SUE Releasees from any causes of action, claims, suits, liabilities or demands of any nature whatsoever including, but in no way limited to, claims of negligence, which I and any and all legal successors and proxies may have, now or in the future, against Releasees on account of personal injury, property damage, disability, death, sickness, diseases or accident of any kind, arising out of or in any way related to the use of Facilities or participation in Programs, whether that participation is supervised or unsupervised, however the injury or damage occurs, including, but not limited to the negligence of Releasees.

In further consideration of the use of Facilities and participation in Programs, I agree to INDEMNIFY AND HOLD HARMLESS Releasees from any and all causes of action, claims, demands, losses, suits, liabilities or costs of any nature whatsoever, including claims of negligence, arising out of or in any way related to the use of Facilities and participation in Programs by myself, my family members, dependents or guests, including any minors.

By checking below, you are indicating that you agree to the Adult Participant Release & Waiver of Liability and Indemnity Agreement. *
Required
By checking this box and typing my name below, I agree that I am electronically signing this document. *
Required
Electronic Signature *
Date *
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