7/31/2019 YES! Teen Registration Packet

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Family and Youth Enrichment

Release of Liability Form: Adults and Minors

Parent/Guardian Name(s) (print)______________________________________________________________________

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

Minor Children Participating:

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

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

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

Active Duty Member Service Branch______________Command _____________________________Rank ______

Deployment Status (list dates if known) ______________________________________________________________

Home Phone__________________________Work__________________________Cell__________________________

Email Address____________________________________________________________________________________

Emergency Contact________________________________________EC Phone Number_______________________

Activity or Group YES! Youth Enrichment in Summer Teen Date(s) August 2nd, 2012

Location Mission Bays Belmont Park _

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.

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

Food Allergies, if any:______________________________________________________________________________

My Child(ren) will _____Walk Home _____Be picked up.

Person(s) other than parents who may pick up child(ren) ___________________________________________________

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

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Camper Name:__________________________________________________________________________________Birth Date:_______/_______/_______ Age:______Sex:___________________

Address:_____________________________________________City:_________________________________State:________Zip:_____________________ Phone: ______________________________

Parent/Guardian 1Name:________________________________________________________________Work:___________________________________Cell:__________________________________

Parent/Guardian 2Name:________________________________________________________________Work:___________________________________Cell:__________________________________

Family Email Address:_______________________________________________________________________________________________________________________________________________________

Emergency Contact Name:______________________________________________________________ Phone:__________________________________ Cell:__________________________________

YMCA CAMPER HEALTH HISTORY FORM 2012

Medical InformationFamily Physician:____________________________________________________ Phone:__________________________________ Date of last physical exam: :_______/_______/_______Medical Insurance Carrier:_____________________________________________________________________________ Policy and/or group #: ______________________________________

Currently under Dr. care Yes No ADD/ADHD Yes No Chicken Pox Yes NoHeart defect/disease Yes No Autism Yes No Measles Yes NoRecent hospitalization Yes No

Aspergers Syndrome

Yes No

German Measles Yes No

Asthma Yes No Bedwetting Yes No Other diseases/conditions Yes NoSeizures Yes No Sleepwalking Yes No __________________________________________________________Diabetes Yes No Tuberculosis Yes No __________________________________________________________

For each Yes, please explain:___________________________________________________________________________________________________________________________________________

AllergiesHay fever Yes No Bee stings Yes No Penicillin Yes NoOak/Ivy poisoning Yes No (Require bee-sting kit) Yes No Other drugs Yes NoFoods Yes No Other insects or animals Yes No Any other allergies? Yes No

to be continued at camp (dosage/frequency): ______________________________________________________________________________________________

___________________________________________________________________________________________________________________________________________________________________________________

Dietary Restrictions? Yes NoAny reason to restrict full activity including swimming, long hikes, strenuous physical games? Yes No

Any current mental, or psychological conditions requiring special consideration or restrictions? Yes NoFor each Yes, please explain:___________________________________________________________________________________________________________________________________________

___________________________________________________________________________________________________________________________________________________________________________________

Non-Prescription Medications I authorize the following medications or generic equivalent to be administered as needed:

Acetaminophen Yes No Hydrocortizone Yes No Pepto Bismol Yes No Benadryl Yes No

Chloraseptic Yes No Cough Drops Yes No Ibuprofen (Advil) Yes No Cough Syrup Yes No

Waiver of LiabilityI, the undersigned parent/person having legalcustody/guardianship of the above said minor, give

permission for the minor to participate in the YMCAprogram described above. The minor is physically ableand mentally prepared to participate in all activities asdescribed in the announcement for the program. Inconsideration of said minor being permitted to enter anybranch of YMCA of San Diego County (YMCA) forobservation, use of facilities and/or equipment, or par-ticipation of the above or any program, I, on behalf ofmyself (as parent, guardian, coach, aide, spectator orparticipant) hereby: 1. Acknowledge that (i)I have readthis document, (ii)I have had the opportunity to inspectthe YMCA facilities and equipment, (iii)I accept them asbeing safe and reasonably suited for the purposesintended and (iv)I voluntarily sign this document. 2.Release YMCA, its directors, officers, employees and

volunteers (collectively Releasees) from all liability tome for any loss or damage to property or injury ordeath to person, whether caused by Releasees or

otherwise and while such minor is in or near any YMCAbranch. 3. I agree not to sue Releasees for any loss,damage, injury or death described above and I willindemnify and hold harmless Releasees and each ofthem from any loss, liability, damage or cost they mayincur due to said minors presence in, upon or near theYMCA branch; whether caused by the negligence ofReleasees. 4. I assume full responsibility for, and riskof, bodily injury, death or property damage due to thenegligence of Releasees or otherwise. 5. I do herebyauthorize the YMCA as agent for the undersigned, toconsent with respect to said minor, to any x-ray exam-ination, anesthetic, medical, dental, or surgical diagno-sis or treatment, and hospital care which is deemedadvisable by, and is to rendered under general orspecial supervision of, any physician and surgeon

licensed under the provisions of the California MedicalPractice Act on the medical staff of any hospital, wheth-er such diagnosis or treatment is rendered at the office

of the physician or at the hospital. I understand thatthe YMCA is not responsible for costs incurred for medi-cal care. I intend this document to be as broad andinclusive as is permitted by the laws of the State ofCalifornia; if any portion hereof is held invalid, I agreethe balance shall continue in full force and effect.

: I give my permission to the YMCA of SanDiego County to use my childs picture or other likenessin any of the YMCAs general publicity and campaignmaterials.

: I agree that any camp participantsbelongings may be searched outside the participantspresence for drugs, alcohol, weapons or other forbiddenobjects.

Signature of Parent/Guardian:__________________________________________________________________ Date:_______/_______/_______

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Immunization History Are all immunizations up to date? Yes No Date of last tetanus shot (if known): :_______/_______/_______

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Ethnicity Black/African American Asian/Pacific Islander Hispanic/Latino(for statistical reporting only) White/Caucasian Native American Other:_____________________________