Russian (Fall 2018)

Sundays (10 classes): September 16-December 16

No classes on 10/7/18, 11/11/18, 11/25/18

Beginner: 12:30PM – 1:30PM
Returning Students: 10:30AM – 11:30AM OR 11:30AM – 12:30 PM

Members: $230 (use coupon code: russian18sunday at Checkout)
Non-Members: $250

Thursdays (13 classes): September 13-December 13

No classes on 11/22/18

Beginner: 5:30PM – 6:30PM
Returning Students: 6:30PM-7:30PM

Members: $260 (use coupon code: russian18thursday at Checkout)
Non-Members: $295

$250.00 – $295.00

Day of Week
Time	Clear

Child Information
Child's Name*
First Last
Gender
Age
Date of Birth*
MM
DD
YYYY
Home Address*
Street Address Address Line 2 City State ZIP Code
Parent/Guardian 1 Name*
First Last
Parent/Guardian 1 Phone Number*
Parent/Guardian 2 Name
First Last
Parent/Guardian 2 Phone Number
Email*
Home Phone Number
How did you hear about us?
Membership*
If yes, Expiration Date*
MM
DD
YYYY
Emergency Contact
Emergency Contact Name*
First Last
Emergency Contact Phone Number*
Relationship to Child*
Product Name
Security Entry Cards
- 0
- 1
- 2
- 3
- 4
For non-members entry only. $5 each for the first 2 cards. $10 each card thereafter. **Non-Refundable**
Waiver text
I hereby give permission to the Kings Bay YM-YWHA, Inc. to take photographs of me and/or my child to be shown in a video, brochure, advertisement, or internet display for purposes of promoting interest in the Kings Bay YM-YWHA. I release the Kings Bay YM-YWHA, Inc. from any claims resulting from the pictures taken on, before, or after the date of this communication. I do hereby give permission for my child to participate in all activities, including off-ground activities. I authorize the Kings Bay YM-YWHA, Inc. to act as parent surrogate on my behalf. I realize that itineraries and/or programs are subject to change prior to, and during, the semester. I hereby give my permission for my child to participate in all programs, swimming, activities and trips as part of the 2018 Kings Bay YM-YWHA Spring children's programming. I understand and fully recognize that risks are involved. I hereby release the Kings Bay YM-YWHA or any of its sponsors, benefactors, or employees from any liability arising out of any injury to my child. In the event of a medical or surgical emergency, I grant permission to the physician designated by the Kings Bay YM-YWHA to hospitalize, secure proper treatment for, and order injections, anesthesia or surgery for my child. Furthermore, I understand that payment for medical services is the solely the family's responsibility.
Waiver*
I hereby give permission to the Kings Bay YM-YWHA, Inc. to take photographs of me and/or my child to be shown in a video, brochure, advertisement, or internet display for purposes of promoting interest in the Kings Bay YM-YWHA. I release the Kings Bay YM-YWHA, Inc. from any claims resulting from the pictures taken on, before, or after the date of this communication. I do hereby give permission for my child to participate in all activities, including off-ground activities. I authorize the Kings Bay YM-YWHA, Inc. to act as parent surrogate on my behalf. I realize that itineraries and/or programs are subject to change prior to, and during, the semester. I hereby give my permission for my child to participate in all programs, swimming, activities and trips as part of the 2018 Kings Bay YM-YWHA Spring children's programming. I understand and fully recognize that risks are involved. I hereby release the Kings Bay YM-YWHA or any of its sponsors, benefactors, or employees from any liability arising out of any injury to my child. In the event of a medical or surgical emergency, I grant permission to the physician designated by the Kings Bay YM-YWHA to hospitalize, secure proper treatment for, and order injections, anesthesia or surgery for my child. Furthermore, I understand that payment for medical services is the solely the family's responsibility.
- I have carefully read the contract and other related information and agree to accept all terms as set forth above.
No refunds will be issued for any classes missed or cancelled. The Kings Bay Y will attempt to offer make-up class.
Signature*
Kings Bay YM-YWHA does not discriminate any person on the basis of race, color, religion, sex, gender identity or expression, sexual orientation, national origin, age, marital status, family status or any other characteristic protected by Federal and State laws. Kings Bay YM-YWHA will make reasonable accommodations in compliance with the Americans with Disabilities Act of 1990. To file a complaint of discrimination, write Office for Civil Rights, U.S. DHHS 26 Federal Plaza - Suite 3313 New York, NY 10278. (212) 264-3313; (212) 264-2355 (TDD); (212) 264-3039 FAX

The Kings Bay YM-YWHA is an equal opportunity provider and employer, and does not discriminate on any basis in accordance with the US Dept of Agriculture policy; nor based on race, color, religion, sex, gender identity or expression, sexual orientation, national origin, age, disability, marital status, family status or any other characteristic protected by Federal or State laws. The Kings Bay YM-YWHA will make reasonable accommodations in compliance with the Americans with Disabilities Act of 1990.

To file a complaint of discrimination, write to the Office for Civil Rights/U.S. DHHS/26 Federal Plaza, Ste 3313/New York, NY 10278. The telephone number is (212) 264-3313 or (212) 264-2355 (TDD); the fax number is (212) 264-3039. To file a complaint of discrimination concerned funded food programs, write to USDA, Director/Office of Civil Rights/1400 Independence Avenue S.W./Washington D.C. 20250-9410. You an also call (866) 632-9992 (voice) or (800) 877-8339 (TDD)

Subtotal
Security Cards
Total

SKU: N/A Category: Specialty Classes

Description
Additional information

Sundays (10 classes): September 16-December 16

No classes on 10/7/18, 11/11/18, 11/25/18

Beginner: 12:30PM – 1:30PM
Returning Students: 10:30AM – 11:30AM OR 11:30AM – 12:30 PM

Members: $230 (use coupon code: russian18sunday at Checkout)
Non-Members: $250

Thursdays (13 classes): September 13-December 13

No classes on 11/22/18

Beginner: 5:30PM – 6:30PM
Returning Students: 6:30PM-7:30PM

Members: $260 (use coupon code: russian18thursday at Checkout)
Non-Members: $295

Additional information

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