Juneteenth Celebration | June 19, 2026

Juneteenth Celebration

June 19, 2026 | 5 PM - 8 PM | Berkeley Heights YMCA
Please complete one registration form per guest. A parent/guardian is required to complete and sign the application for minors under the age of 18.
Is the attendee 18 years of age or older?
GUEST INFORMATION
Guest Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date of Birth

MonthDayYear
Email
example@example.com
Member Status

Other
Which one of the following best represents your ethnic heritage?

Other
Will you be using the Berkeley Heights YMCA pool? (Opens at 4pm)
Please note: Y-USA requests the above information from YMCA participants throughout the nation for program funding and demographic purposes.
- Parent/Guardian Name
  
  First NameLast Name
- Relationship to Minor
- Date of Birth
  
  MonthDayYear
- Phone Number
  ex. 555-555-5555Format: 000-000-0000.
- Parent/Guardian Email
  example@example.com
- Do you want to provide Emergency Contact information that is different from the Parent/Guardian information provided above?
- EMERGENCY CONTACT INFORMATION
- Name
  
  First NameLast Name
- Phone Number
  ex. 555-555-5555Format: 000-000-0000.
- Relationship to You
- Waiver and Release of Liability
- Coronavirus/COVID-19 Warning & Disclaimer
- Code of Conduct
- Photo, Video and Audio Recording Release
- Please verify that you are human
- Signature
- Use your mouse or finger to draw your signature.
- Date
  
  MonthDayYear
  Date
- Should be Empty: