WOODSON
Please print clearly and fill in all information
Account Set-up Information (Parent’s Info)
Email address:
______________________________________________________________________
________________
Mail To First Name: __________________________ Mail To Last Name:
__________________________
Billing Address:
______________________________________________________________________
_______________
Zip Code: City: _______________________
_______________________
State: _____________
Home Phone: ______________________________ Cell Phone:
____________________________________
Member(s) Set-up (Swimmer’s Information)
Member #1:
First Name: ____________________________________ Last Name:
____________________________________
Gender (Cirlce One): Male Female Birthday:
___________/___________/___________
Practice Group (Select One): ___ Spotted (Orange) ___ Spinner (Green) ___ Bottlenose (Blue I)
___ Risso (Blue II) ___ Rough-Tooth (Silver) ___ Killer Whales (Gold)
Primary Practice Location (Select One): ____ Aspirus ___ Mosinee ___ Wausau
Member #2:
First Name: ____________________________________ Last Name:
____________________________________
Gender (Cirlce One): Male Female Birthday:
___________/___________/___________

Practice Group (Select One): ___ Spotted (Orange) ___ Spinner (Green) ___ Bottlenose (Blue I)
___ Risso (Blue II) ___ Rough-Tooth (Silver) ___ Killer Whales (Gold)
Primary Practice Location (Select One): ____ Aspirus ___ Mosinee ___ Wausau
Member #3:
First Name: ____________________________________ Last Name:
____________________________________
Gender (Cirlce One): Male Female Birthday:
___________/___________/___________
Practice Group (Select One): ___ Spotted (Orange) ___ Spinner (Green) ___ Bottlenose (Blue I)
___ Risso (Blue II) ___ Rough-Tooth (Silver) ___ Killer Whales (Gold)
Primary Practice Location (Select One): ____ Aspirus ___ Mosinee ___ Wausau Continue 
Current
Prices
Spotted
$109 / $77
Amount Requested:
Spinner
$109 / $77
Financial Information
Bottlenose
$109 / $77
Risso
$109 / $77
Rough-Tooth
$117 / $88
Killer Whales
$117 / $88
____ Full Scholarship (Extreme Circumstances must exist)
____ Partial Scholarship - I can pay $_____________ per month.
____ Fixed amount Scholarship – I need $_________ for the season.
We receive a Y Scholarship for our membership (Select One): Yes No
I want to spread my payments as follow (Select One):
1 Payment 2 Payments 3 Payments 6 Payments
I agree to the following:
I certify that I am the parent or legal guardian for my child(ren). I hereby give my permission for any supervisor, coach or other team administrator associated with the Wausau Area Y Swimming to seek and give appropriate medical attention for our child(ren) in the event of accident, injury, illness. I will be responsible for any and all costs associated with any necessary medical attention and/or treatment.
I hereby waive, release and forever discharge Wausau Area Y Swimming and associated supervisor, coach or other team administrator from all rights and claims for damages, injury, loss to person or property which may be sustained or occur during participation in Wausau Area Y Swimming activities, whether or not damages or loss is due to negligence. I hereby acknowledge that my children is (are) physically fit and capable of participation in all Swim Team activities.
By registering my child(ren) with the Wausau Area Y Swimming , I agree to participate (or allow my child(ren) and family members to participate) in the Wausau Area Y Swimming , and hereby release Wausau Area Y Swimming , its directors, officers, agents, coaches, and employees from liability for any injury that might occur to myself (or to my child(ren) and family members) while participating in the Wausau Area Y Swimming program, including travel to and from training

sessions, swim meets or other scheduled team activities.
I agree to indemnify and hold harmless the above mentioned organizations and/or individuals, their agents and/or employees, against any and all liability for personal injury, including injuries resulting in death to me, my child(ren) and/or other family members, or damage to my property, the property to my child(ren) and/or other family members, or both, while I
(or my child(ren) or family members) participating in the Wausau Area Y Swimming program.
I have received and viewed a copy of the Wausau Area Y Swimming Handbook dated 2011-2012 Edition. I understand my obligations to my swimmer and the team. A copy of the handbook can be found online.
I agree that I may need to provide financial records to process my scholarship. These items will be requested by Pam Soja,
Head Swim Team Coach. Please do not provide any financial records unless asked.
______________________________________________________________________
_ _____________________________
Signature Date
Please submit forms to Pam Soja, Head Swim Coach at:
Woodson YMCA-Wausau Branch
707 3 rd Street
Wausau, WI 54403 or psoja@woodsonymca.com