Form Yl6007 - Camping Health, Consent And Release Form (Page 2 of 2) in pdf

List any medication/treatment to be continued at camp (specify dosages)

Name of family physician

Phone (

)

Name of dentist

Phone (

)

Orthodontist

Phone (

)

IMMUNIZATIONS

HEALTH HISTORY

Check if applicant has:

Has applicant had (include date):

 Check and date any immunizations the applicant has received, or

 Asthma

 Chicken Pox

 Applicant has not been immunized for:

 Bleeding/Clotting Disorder

 medical  personal  or religious reasons.

 Measles

 Convulsions in last 60 days

 German Measles

 DTaP (Diphtheria, Tetanus, & Pertussis) Date:

 Diabetes

 Mumps

 TD (Tetanus and Diphtheria)

Date:

 Epilepsy

 Hepatitis A

 MMR (Measles, Mumps, Rubella)

Date:

 Frequent Ear Infections

 Hepatitis B

 Polio (OPV or IPV)

Date:

 Heart Defect/Disease

 Hepatitis C

 Hepatitis B

Date:

 Hypertension

 Mononucleosis

 Sickle Cell

 Varicella (Chicken Pox)

Date:

 HIB (Haemophilus influenza B)

Date:

 Currently Pregnant

Due Date:

 Other

Date:

 Delivered baby in last 12 weeks

Delivery Date:

ALLERGIES (List any food, drug, plant, insect, or other allergies)

PROTECTIVE CUSTODY ARRANGEMENTS

Is there a court order in place that lists certain persons who are or are not authorized to pick up your child from camp?  YES  NO

If yes, the following people are allowed to pick my child up from camp

If yes, the following people are NOT allowed to pick my child up from camp

Signature of parent/guardian

Date



SIGN

AUTHORIZATION FOR TREATMENT

This health history is correct to the best of my knowledge, and the person herein named has permission to engage in all camp activities except as noted. I hereby give permission to the medical

personnel selected by the camp director to order X-rays, routine tests, treatment; to maintain and/or release any medical records necessary for insurance purposes as outlined under the HIPAA

regulations*; and to provide or arrange necessary related transportation for me or my child. In an emergency, I hereby give permission and authorize the physician selected by Young Life to

secure or administer emergency medical treatment, including hospitalization and any other emergency medical procedures which may be needed for the person named herein. I authorize the

physician or dentist to call in any necessary consultants in his/her discretion. It is understood that this consent is given in advance of any specific diagnosis or treatment being required, and is

given to encourage those persons who have temporary custody of the minor, and said physician or dentist to exercise their best judgment as to the requirements of such diagnosis or medical,

dental or surgical treatment. In addition, I authorize camper to carry emergency medications and use as directed.



SIGN

Parent/Guardian/Adult Applicant Signature

Date

I agree to remain fully liable and responsible for the payment of any such hospital, doctor, ambulance, dental or medical fees with the exception of the Accident Coverage as set out herein. I

further agree that in giving this permission and authorization, Young Life does not assume any responsibility or liability for the payment of such hospital, doctor, ambulance, dental or other

medical fees which may be incurred. The completed forms may be photocopied and maintained by authorized personnel for trips out of camp.



Parent/Guardian/Adult Applicant Signature

Date

SIGN

*I have received, reviewed, and agree to the release of my health information as outlined in Young Life’s “Notice of Privacy Practices” handout. Additional copies available at



Parent/Guardian/Adult Applicant Signature

Date

SIGN

ACKNOWLEDGEMENT OF INHERENT RISK

I ACKNOWLEDGE AND UNDERSTAND THERE ARE INHERENT RISKS ASSOCIATED WITH MANY CAMP ACTIVITIES. I WILL ASSUME THE RISK ASSOCIATED THEREWITH, WHETHER

KNOWN OR UNKNOWN TO ME AT THIS TIME. I RECOGNIZE THAT MY ATTENDANCE AT A YOUNG LIFE CAMP IS A PRIVILEGE AND AS A CONSIDERATION FOR THIS PRIVILEGE, I

RELEASE YOUNG LIFE, INCLUDING ITS EMPLOYEES, AGENTS AND TRUSTEES, FROM RESPONSIBILITY FOR MY ACCIDENTAL PHYSICAL INJURY, INCLUDING DEATH OR

ILLNESS, AND LOSS OF PERSONAL PROPERTY WHILE AT CAMP OR DURING YOUNG LIFE SPONSORED TRAVEL TO AND FROM CAMP. THIS RELEASE IS ALSO INTENDED TO

INCLUDE ALL CLAIMS MADE BY MY FAMILY, ESTATE, HEIRS, PERSONAL REPRESENTATIVE OR ASSIGNS. I GRANT PERMISSION FOR MY CHILD TO PARTICIPATE IN ALL

SPECIAL TRIPS OFF THE CAMP PROPERTY WITH PROPER STAFF SUPERVISION.



SIGN

Parent/Guardian/Adult Applicant Signature

Date

UNDER COLORADO LAW, AN EQUINE PROFESSIONAL IS NOT LIABLE FOR ANY INJURY TO OR THE DEATH OF A PARTICIPANT IN EQUINE ACTIVITIES RESULTING FROM THE

INHERENT RISKS OF EQUINE ACTIVITIES, PURSUANT TO SECTION 13-21-119, COLORADO REVISED STATUTES.

UNDER ARIZONA LAW, A SIGNED RELEASE ACKNOWLEDGES THAT THE PERSON IS AWARE OF THE INHERENT RISKS ASSOCIATED WITH EQUINE ACTIVITIES, IS WILLING AND

ABLE TO ACCEPT FULL RESPONSIBILITIES FOR HIS OWN SAFETY AND WELFARE AND RELEASES THE EQUINE OWNER OR AGENT FROM LIABILITY UNLESS THE EQUINE

OWNER OR AGENT IS GROSSLY NEGLIGENT OR COMMITS WILLFUL, WANTON OR INTENTIONAL ACTS OR OMISSIONS.

WAIVER AND RELEASE

IF I AM UNDER AGE 18, MY PARENT OR GUARDIAN, BY SIGNING BELOW, ALSO CONSENTS TO MY RELEASE AND HE OR SHE AGREES THAT THIS RELEASE SHALL BE BINDING

UPON HIM OR HER AS MY PARENT OR GUARDIAN AS TO ME AND MY ESTATE, HEIRS, PERSONAL REPRESENTATIVES AND ASSIGNS. MY PARENT OR GUARDIAN ALSO

PROMISES, BY SIGNING BELOW TO DEFEND, INDEMNIFY AND HOLD YOUNG LIFE HARMLESS FROM ANY CLAIM ASSERTED BY ME AGAINST YOUNG LIFE, INCLUDING ITS

TRUSTEES, EMPLOYEES AND AGENTS, IF I SHOULD REPUDIATE THIS RELEASE AFTER OBTAINING ADULTHOOD.

PHOTO RELEASE

I HEREBY GRANT PERMISSION TO YOUNG LIFE THE RIGHT TO USE, REPRODUCE, AND/OR DISTRIBUTE PHOTOGRAPHS, FILMS, VIDEOTAPES, AND SOUND RECORDINGS OF

MY CHILD, WITHOUT COMPENSATION OR APPROVAL RIGHTS, FOR USE IN MATERIALS CREATED FOR PURPOSES OF PROMOTING THE ACTIVITIES OF YOUNG LIFE.



SIGN

Parent/Guardian/Adult Applicant Signature

Date

Applicant understands and agrees to abide with the restrictions placed on his/her camp activities as listed herein. Parent/Guardian may sign for minor, acknowledging their agreement.



SIGN

Parent/Guardian/Adult Applicant Signature

Date

(If camper is emancipated, proof must be provided prior to camp.)

YL6007 (Mar 2013)