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Youth and Community Outreach DepartmentRelease of Liability Form: Adults and Minors

Activity or Group______Leaders in Training - Retreat_________________Date(s)__May 11th

to May 13th

__________

Location _______Armed Services Y and Camp Surf Y_____________________________________________________

Minor Child(ren) Participating:

Name_______________________________ Gender ______ Date of Birth ________________ Special Needs? YES/NO

Name_______________________________ Gender ______ Date of Birth ________________ Special Needs? YES/NO

_______YES My child(ren) can receive a healthy snack _______NO My child(ren) cannot receive a healthy snack

Childs Food Allergies, if any (list in order):____________________________________________________________

My child will: _____ Walk Home _____ Drive Home Be picked up

Individual(s) authorized to pick up my child include:

Parent/Guardians Information:

Parent/Guardian Name(s) (print) _____________________________________________________________________

Parents Date(s) of Birth (same order) _________________________________________________________________

Active Duty Member Service Branch______________Command _____________________________Rank ______

Deployment Status (list dates if known) ______________________________________________________________

Home Phone__________________________Work__________________________Cell__________________________

Email Address______________________________________________________________Military Housing? Yes/No

Address______________________________________________________City________________Zip____________

Emergency Contact________________________________________EC Phone Number_______________________

I, the undersigned parent/person having legal custody/guardianship of the above said minor, give permission for theminor to participate in the San Diego Armed Services YMCA program described above. I hereby grant fullpermission for my child and/or myself to be photographed by the San Diego Armed Services YMCA staff for anylegitimate purpose without payment or compensation. The minor is physically able and mentally prepared toparticipate in all activities as described in the announcement for the program. I hereby voluntarily and knowinglyassume all risks and dangers inherent and incidental to the activities of the program. I will not hold the San DiegoArmed Service YMCA liable for any injuries incurred during the program or while my child(ren) is/are in transit to andfrom the program whether caused by equipment or the act or omissions of others excepting damage or injury solelycaused by the willful misconduct or negligence of the San Diego Armed Services YMCA, or its employees,volunteers, or agents.

I do hereby authorize the San Diego Armed Services YMCA as agent for the undersigned, to consent with respect tothe minors, to any x-ray examination, anesthetic, medical, dental, or surgical diagnosis or treatment, and hospitalcare which is deemed advisable by, and is to be rendered under general or special supervision of, any physicianand surgeon licensed under the provisions of the California Medical Practice Act on the medical staff of any hospitalwhether such diagnosis or treatment is rendered at the office of the physician or at the hospital. I understand thatthe San Diego Armed Services YMCA is not responsible for costs incurred for medical care. If I participate in theprogram, whether as coach, instructor, aide, spectator, or participant, I presently waive as to the San Diego ArmedServices YMCA and staff, officers and directors thereof, any claim presently known or unknown for damage toproperty or personal injury whether caused by equipment or the acts or omissions of others including San DiegoArmed Services YMCA personnel.

****Parent/Guardian (Signature)____________________________________Date___________________****

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YMCA Camp Sur f Phone: 619-423-5850 www.camp.ymca.org

YMCA Camper Health History Form* * * ATTENTION- Required for attendance by all youth campers under the age of 18* **

Camper Name: Birth Date: Age: Sex:

Street Address: City: State: Zip Code:

Name of Parent/Guardian1: Phone (H): (W):

Alternate/Emergency Contact: Emergency Phone:

(Last) (First) (MI)

WAIVER OF LIABILITY- Signature required for camp attendance.

I, the undersigned parent/person having legal custody/guardianship of the above said minor, give permission for the minor to part icipate in the YMCA program describedabove. The minor is physically able and mentally prepared to part icipate in all activit ies as described in the announcement for the program. In consideration of said minorbeing permitted to enter any branch of YMCA of San Diego County ( YMCA) for observation, use of facilities and/or equipment, or participation of the above or anyprogram, I, on behalf of myself (as parent, guardian, coach, aide, spectator or participant) hereby: 1. Acknowledge that (i)I have read this document, (ii)I have had theopportunity to inspect the YMCA facilities and equipment, (iii)I accept them as being safe and reasonable suited for the purposes intended and (iv)I voluntarily sign thisdocument. 2. Release YMCA, its directors, officers, employees and volunteers (collectively Releasees) from all liabilit y to me for any loss or damage to property orinjury or death to person, whether caused by Releasees or otherwise and while such minor is in or near any YMCA branch. 3. I agree not to sue Releasees for any loss,damage, injury or death described above and I will indemnify and hold harmless Releasees and each of them from any loss, liability, damage or cost they may incur due tosaid minor s presence in, upon or near the YMCA branch; whether caused by the negligence of Releasees. 4. I assume full responsibility for, and risk of, bodily injury,

death or property damage due to the negligence of Releasees or otherwise. 5. I do hereby authorize the YMCA as agent for the undersigned, to consent with respect tosaid minor, to any x-ray examination, anesthetic, medical, dental, or surgical diagnosis or treatment, and hospital care which is deemed advisable by, and is to renderedunder general or special supervision of, any physician and surgeon licensed under the provisions of the California Medical Practice Act on the medical staff of any hospital,whether such diagnosis or treatment is rendered at the office of the physician or at the hospital. I understand that the YMCA is not responsible for costs incurred formedical care. I intend this document to be as broad and inclusive as is permitt ed by the laws of the State of California; if any port ion hereof is held invalid, I agree thebalance shall continue in full force and effect.

Signature of Parent or Guardian:X Date:

Family Physician: Phone: Date of last physical exam:

Medical Insurance Carrier: Policy and/or Social Security #: Group #:

Asthma mYes mNo

Heart Defect/Disease mYes mNoRecent Hospitalization mYes mNo

Currently under Dr .s care mYes mNoSeizures mYes mNo

Diabetes mYes mNo

ADD/ADHD mYes mNo

Head Lice (recent) mYes mNoBedwetting mYes mNo

Sleepwalking mYes mNoTuberculosis mYes mNo

Chicken Pox mYes mNo

Measles mYes mNo

German Measles mYes mNoOther Diseases or Conditions

mYes mNo

Medical Infor mation past or present ( please check):

For eachm yes, please explain:Allergies:

Non-Prescript ion Medications: I authorize the following medications to be administered as needed:

Hay Fever mYes mNo

Oak/Ivy Poisoning mYes mNoFoods mYes mNo

Bee Stings mYes mNo

Bee Sting Kit? mYes mNoOther insects/animals mYes mNo

Penicillin mYes mNo

Other Drugs mYes mNoAny other allergies? mYes mNo

Current medications to be continued at camp (dosage/frequency):

Dietary restr ictions?mYes mNoAny reason to restrict full activity, including swimming, long hikes or strenuous physical games?mYes mNo

If yes, please explain:

Tylenol mYesmNo

Chloraseptic mYesmNo

Sucrets mYesmNo

Cough Drops mYesmNo

Pepto Bismol mYesmNo

Ibuprofen mYesmNo

Benadryl mYesmNo

Cough Syrup mYesmNo