Youth and Community Outreach Department Release of Liability Form: Adults and Minors

Activity or Group______Leaders in Training - Retreat_________________ Date(s)__May 11 to May 13 __________ Location _______Armed Services Y and Camp Surf Y_____________________________________________________

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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 the minor to participate in the San Diego Armed Services YMCA program described above. I hereby grant full permission for my child and/or myself to be photographed by the San Diego Armed Services YMCA staff for any legitimate purpose without payment or compensation. The minor is physically able and mentally prepared to participate in all activities as described in the announcement for the program. I hereby voluntarily and knowingly assume all risks and dangers inherent and incidental to the activities of the program. I will not hold the San Diego Armed Service YMCA liable for any injuries incurred during the program or while my child(ren) is/are in transit to and from the program whether caused by equipment or the act or omissions of others excepting damage or injury solely caused 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 to the minors, to any x-ray examination, anesthetic, medical, dental, or surgical diagnosis or treatment, and hospital care which is deemed advisable by, and is to be rendered under 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 San Diego Armed Services YMCA is not responsible for costs incurred for medical care. If I participate in the program, whether as coach, instructor, aide, spectator, or participant, I presently waive as to the San Diego Armed Services YMCA and staff, officers and directors thereof, any claim presently known or unknown for damage to property or personal injury whether caused by equipment or the acts or omissions of others including San Diego Armed Services YMCA personnel.

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

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

YMCA Camper Health History Form

*** Camper Name: Street Address:
(Last) (First) (MI)

ATTENTION - Required for attendance by all youth campers under the age of 18***
Birth Date: City: Phone (H): Emergency Phone: State: Age: Zip Code: (W): Sex:

Name of Parent/Guardian1: Alternate/Emergency Contact: 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 participate in the YMCA program described above. The minor is physically able and mentally prepared to participate in all activities as described in the announcement for the program. In consideration of said minor being 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 any program, 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 the opportunity 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 this document. 2. Release YMCA, its directors, officers, employees and volunteers (collectively Releasees) from all liability to me for any loss or damage to property or injury 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 to said minors 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 to said 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 rendered under 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 for medical care. I intend this document to be as broad and inclusive as is permitted by the laws of the State of California; if any portion hereof is held invalid, I agree the balance shall continue in full force and effect.

Signature of Parent or Guardian:

Family Physician: Medical Insurance Carrier:

Date: Phone: Date of last physical exam: Group #:

Policy and/or Social Security #:

Medical Information past or present (please check): Asthma Heart Defect/Disease Recent Hospitalization
Currently under Dr.s care

Seizures Diabetes

mYes mYes mYes mYes mYes mYes

mNo mNo mNo mNo mNo mNo

ADD/ADHD Head Lice (recent) Bedwetting Sleepwalking Tuberculosis Chicken Pox

mYes mYes mYes mYes mYes mYes

mNo mNo mNo mNo mNo mNo

Measles mYes German Measles mYes Other Diseases or Conditions mYes

mNo mNo mNo

For each m yes, please explain: Allergies: Hay Fever Oak/Ivy Poisoning Foods mYes mYes mYes mNo mNo mNo Bee Stings Bee Sting Kit? Other insects/animals mYes mYes mYes mNo mNo mNo Penicillin Other Drugs Any other allergies? mYes mYes mYes mNo mNo mNo

Current medications to be continued at camp (dosage/frequency): Dietary restrictions? mYes mNo Any reason to restrict full activity, including swimming, long hikes or strenuous physical games? mYes mNo If yes, please explain: Non-Prescription Medications: I authorize the following medications to be administered as needed: Tylenol Chloraseptic mYesmNo Sucrets mYesmNo Cough Drops mYesmNo Pepto Bismol mYesmNo Ibuprofen mYesmNo Benadryl mYesmNo Cough Syrup mYesmNo mYesmNo