SENIOR DIVISION & CLUB ADVISOR
ENROLLMENT FORM
2017 YMCA BLUE RIDGE LEADERS’ SCHOOL
FORMS MAY BE TYPED OR HANDWRITTEN
Please check:
Club Advisor (only one per Club)
(will be enrolled in Senior Division)
Date of Birth:
Senior (limit one per fifteen leaders)
Age (as of May 31):
T-Shirt Size:
S
M
L
XL
Female
Male
XXL
Cell Phone:
Name:
Street Address:
City:
State:
Zip:
Email:
YMCA Name:
YMCA Phone:
YMCA Supervisor’s Name:
Supervisor’s Cell Phone:
This is my
This is my
year at Blue Ridge Leaders' School
Any physical conditions, injury or illness that will effect your involvement at BRLS?
explain:
year in the Senior Division
Yes
No
If yes, please
Are you under any medication? (list):
Dietary Restrictions? (list):
Allergies? (list):
NOTE: BOTH SIGNATURES BELOW (*) ARE REQUIRED TO PROCESS THIS ENROLLMENT.
In consideration of the acceptance of this enrollment I hereby waive, release and forever discharge YMCA Blue Ridge Leaders’
School, YMCA Blue Ridge Assembly, the YMCA and their respective staff members, employees and representatives from any
and all claims, liabilities, damages and/or related expenses resulting from or related to my participation in Leaders’ School
activities. I understand that YMCA Blue Ridge Leaders’ School does not carry accident insurance on the participants. I agree
that YMCA Blue Ridge Leaders’ School may photograph or videotape me and may use those photographs and videotapes for
its marketing purposes and I release YMCA Blue Ridge Leaders’ School from any claim or liability related to that use and
waive all claims for myself, my heirs and assignees against YMCA Blue Ridge Leaders’ School.
*Enrollee’s Signature
Date
I attest that the enrollee named above is active in our Physical Education and/or Leaders’ Club program. I assume all
responsibility for the conduct and actions of this individual as a representative of his/her YMCA.
*YMCA Executive Director’s Signature
*
*
Date Received
*
*
*
*
*
*
Amount Paid $
Date
YMCA Blue Ridge Office Use Only
Amount Due $
*
*
*
*
*
*
*
*
*
Room #
Print pages 1 & 2 of the Seniors’ Division Enrollment form and copy onto single page front/back - white paper ONLY. Do not staple.
Page 1 of 2
Name:
Course Requirements

2 Senior Class Periods

Assist in At least 2 Leaders Division Classes a

Optional: 5th period Senior Class Certification and/or Assistance in a Clinic

Dorm Duty: 1 night during the week plus Friday
Seniors’ Division Enrollment Form-Page 2
Class Schedule: Check the classes you would like to participate in (Senior class on first row) and the Leaders’ Division classes you
would like to assist with ONLY ONE CLASS PER PERIOD.
1st Period
9:15 - 10:20 am
Senior Class Period 1
2nd Period
10:35 - 11:40 am
3rd Period
1:30 - 2:35 pm
4th Period
2:50 - 3:55 pm
5th Period
4:10 - 5:15 pm
Evening Clinic
7:15 - 8:30 pm
Senior Class Period 2
Senior Class Period 3
Senior Class Period 4
Senior Class Certification
Aerobics Combo
Aquatics
Adv. Character Development
Aquatics
Adv. Character Development
Adv. Character Development
Aquatics *
Basic Games
Aquatics
Aquatics II
Aquatics
Aquatics
Backyard Games
Biomechanics
Basic Games
Basic Games
Aquatics II
Basic Games
Basketball *
Character Development
Basketball
Basketball
Basic Games
Biomechanics
Cheerleading/Tumbling
Coach/Officiate Sports
Biomechanics
Biomechanics
Biomechanics
Character Development
Cycling/Circuit Training
Feeling Great
Character Development
Character Development
Character Development
Feeling Great
Dance Blast
Flag Football
Coach/Officiate Sports
Coach/Officiate Sports
Coach/Officiate Sports
Field Hockey
Dancing w/the Stars
Frisbee Golf
Feeling Great
Feeling Great
Cross Training
Fit Kids
Dodgeball
HEPA
Field Hockey
Frisbee Golf
Fit Kids
Flag Football
Eco Challenge
Kids in Motion
Flag Football
Group Exercise
Feeling Great
HEPA
Field Hockey
Science of Fitness I
Gymnastics
Gymnastics
Flag Football
Junior Lifeguard
Flag Football
Science of Fitness II
HEPA
Jump Rope
HEPA
Kids in Motion
Frisbee Golf
Tennis
Junior Lifeguard
Kids in Motion
Kids in Motion
Lacrosse
Gymnastics*
Ultimate Frisbee
Kids In Motion
Science of Fitness I
Science of Fitness I
Science of Fitness I
Jump Rope
Volleyball
Science of Fitness I
Science of Fitness II
Science of Fitness II
Science of Fitness II
Junior Lifeguard
Science of Fitness II
Soccer
Soccer
Strength Training
Kettle Works
Soccer
Strength Training
Strength Training
Volleyball
Outdoor Adventure
Ultimate Frisbee
Tennis
Volleyball
Volleyball II
Power Yoga
Ultimate Frisbee
Volleyball II
Wiffle Ball
Quidditch
Volleyball
Wiffle Ball
Soccer *
Tennis *
Triathloning
Ultimate Frisbee
Volleyball *
Water Sports
Zumba
* Progressive skills recognition available.
If my chosen “Leaders’ Division Classes” are full, I would like (complete all three):
1.
Or 2.
Or 3.
DORM DUTY: 1 night during week + Friday Please list your first and second choices (i.e. Monday)
1.
Or 2.
OFFICE HELP: If interested in helping in the School office during free time/free periods please indicate below by typing Yes
(this would include picture sales and other administrative tasks)
1.
SENIOR SOCIALS: If interested in helping plan the senior and senior/staff socials indicate below by typing Yes
1.
If my chosen “optional clinic assistance” is full I would like (complete all three):
1.
Or 2.
Or 3.
Mail all delegation registrations to: Brianne Pietronicco, Blue Ridge Leaders’ School, P.O. Box 989 Lake Villa, IL 60046.
Print pages 1 & 2 of the Seniors’ Division Enrollment form and copy onto single page front/back - white paper ONLY. Do not staple.
Page 2 of 2