GYC Membership Form 23-24 school year
  • Please complete form if new member, every year a new form must be filled out.
  • Household siblings can use the same form.
  • All information must be signed and complete. 
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Email *
Member's Full Name/Grade  *
Member's Date of Birth *
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Physical Address *
Physical address same as mailing? Mailing needed if not the same *
City/State *
Zip Code *
Primary Contact Name/Relation/Number/Email *
Secondary Contact Name/ Relation/ Number/Email 
 *
EMERGENCY CONTACT (If primary and secondary cannot be reached) Name/Relation/Number *
Allergies/Medical Concerns of Member *
Between the hours of GYC Monday-Friday
Is the member allowed to leave GYC? 
 *
I, the Member named below understand, that inappropriate language, behavior, gestures and any threatening activity will not be tolerated. I will respect myself and others and refrain from this type of behavior. I understand my membership can be revoked or suspended if I engage in such activity. I also understand that I am responsible for reading the member handbook and will be held accountable to its contents.  https://www.greenwichyouthcenter.org/uploads/8/4/0/0/84007340/member_handbook_2020.pdf                                                   
 Please have your child type their name to acknowledge they have read the handbook. 
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I, the parent/guardian named below understand, and have read the handbook and agree to my child being held to the rules it dictates while at GYC. https://www.greenwichyouthcenter.org/uploads/8/4/0/0/84007340/member_handbook_2020.pdf)                        Please type your name below to acknowledge that you have read and agree to the rules listed in our handbook *
𝐖𝐚𝐢𝐯𝐞𝐫 𝐚𝐧𝐝 𝐂𝐨𝐧𝐬𝐞𝐧𝐭: I hereby release and waive the  Citizens Committee for Greenwich Youth (CCGY), the Village of Greenwich, employees, agents, representatives, officers, and directors from any and all liability for any loss or injury sustained or incurred (including any loss or injury resulting from the representatives, officers, and directors) while my child/member participates in Greenwich Youth Center’s programs or while my child travels to or from the GYC programs or activities. *
𝐇𝐞𝐚𝐥𝐭𝐡 𝐖𝐚𝐢𝐯𝐞𝐫: I acknowledge that I am aware that there are risks to me and my minor chid of exposure to directly or indirectly  arising out of, contributed to, by, or resulting from an outbreak of any and all communicable disease, including but not limited to, the virus “severe acute respiratory syndrome, coronavirus 2 (SARS-CoV-2)”, which is responsible for Coronavirus Disease (COVID-19) and/or any mutations or various thereof and I KNOWINGLY AND FREELY ASSUME ALL SUCH RISKS and ASSUME ALL SUCH RISKS ON BEHALF OF MY MINOR CHILD, both known and unknown, EVEN IF SUCH RISKS ARISE FROM NEGLIGENCE OF THE RELEASEES or others, and assume full responsibility for my and my minor child's participation. *
𝐈𝐧 𝐚𝐧 𝐄𝐦𝐞𝐫𝐠𝐞𝐧𝐜𝐲: I authorize any First Aid Responders and/or Physicians to perform any and all medical procedures, which he/she determines to be medically appropriate for my child under the circumstance *
𝐀𝐜𝐚𝐝𝐞𝐦𝐢𝐜 𝐏𝐚𝐫𝐭𝐧𝐞𝐫𝐬: I give permission for my child to participate in the tutoring program offered by GYC. I give permission for my child to participate in any educational programing offered by GYC. *
𝐌𝐞𝐝𝐢𝐚 𝐂𝐨𝐯𝐞𝐫𝐚𝐠𝐞: During any GYC activity, media coverage (photography, interviews) may occur. I consent to my child’s picture being taken/posted/advertised in support of the GYC *
I acknowledge as the parent/ guardian that all information given here is accurate by typing my name below. (Please type your name to be acknowledged here as your signature) *
I acknowledge as the member that all information given here is accurate by typing my name below. (Please have your child type their name to be acknowledged here as their signature) *
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