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Get YMCA Medical Release & Liability Waiver

ISCELLANEOUS INFORMATION REQUIRED BY STATE LAW PLEASE PRINT IN INK NAME OF HEALTH INSURANCE CO. CHILD’S NAME POLICY NUMBER BIRTHDATE (MO./DAY/YEAR) AGE FAMILY DOCTOR NAME FEMALE MALE HOME ADDRESS PHONE NUMBER CITY/STATE/ZIP HOME PHONE DENTIST NAME MOTHER’S NAME WORK PHONE PHONE NUMBER FATHER’S NAME WORK PHONE PARENT/GUARDIAN E-MAIL ADDRESS  YMCA of San Diego County Branch I, the undersigned parent/person having legal custody/guardianship of the above said minor, give.

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