The Ymca General Information, Medical History & Release Forms (Page 4 of 4) in pdf

General Information, Medical History & Release Forms for B.R. Ryall YMCA

Statement of accuracy of health history and release for medical treatment

This health history is correct and complete as far as I know, and the person herein described has permission to engage in all activities except as noted. I hereby give

permission to the B.R. Ryall YMCA and its staff to provide routine health care, administer prescribed medications and seek emergency medical treatment including

ordering x-rays or routine tests. I agree to the release of any records necessary for treatment, referral, billing or insurance purposes. I give permission to the B.R.

Ryall YMCA to arrange necessary related transportation for me/my child. In the event I cannot be reached in an emergency, I hereby give permission to the physician

selected by the B.R. Ryall YMCA to secure and administer treatment, including hospitalization, for the person named above. This completed for may be photocopied

for program trips.

Parent/Guardian Signature _____________________________________________________________________________________________________________ Date ________________________________________

Photo Release

I hereby give my permission and consent to the use of photographs, videotapes or other media record of my or my child’s participation at the B.R. Ryall YMCA for lawful

purposes without compensation to me or my behalf. If I choose not to be photographed, videotaped or in other recorded media, or to have my child photographed,

videotaped or in other recorded media, I understand it is my responsibility to inform the photographer and/or to remove myself or my child from the picture.

Parent/Guardian Signature ______________________________________________________________________________________________________________ Date _______________________________________

Release, Indemnification and Hold Harmless Agreement

Inconsideration of participating in YMCA activities, and for other good and valuable consideration, I hereby agree to release and discharge from liability arising from

negligence the B.R. Ryall YMCA and its owners, directors, employees, agents, volunteers, participants and all other persons or entities acting for them (hereinafter

collectively referred to as “Releasees”), on behalf of myself and my children, parents, heirs, assigns, personal representative and estate, and also agree as follows:

1. I acknowledge that participating in YMCA activities involves known and unanticipated risks which could result in physical or emotional injury, paralysis or

permanent disability, death and property damage. Risks include, but are not limited to, broken bones, torn ligaments or other injuries as a result of falls or contact

with other participants; death as a result of drowning or brain damage caused by near drowning in pools or other bodies or water; medical conditions resulting

from physical activity; and damaged clothing or other property. I understand such risks simply cannot be eliminated, despite the use of safety equipment, without

jeopardizing the essential qualities of the activity.

2. I expressly accept and assume all of the risks inherent in this activity or that might have been caused by the negligence of the Releasees. My participation in this

activity is purely voluntary and I elect to participate despite the risks. In addition, if at any time I believe that event conditions are unsafe or that I am unable to

participate due to physical or medical conditions, then I will immediately discontinue participation.

3. I hereby voluntarily release, forever discharge, and agree to indemnify and hold harmless Releasees from any and all claims, demands, or causes of action which

are in any way connected with my participation in this activity, or my use of their equipment or facilities, arising from negligence. This release does not apply to

claims arising from intentional conduct. Should Releasees or anyone acting on their behalf be required to incur attorney’s fees and cost to enforce this agreement,

I agree to indemnify and hold them harmless for all such fees and costs.

4. I represent that I have adequate insurance to cover any injury or damage I may suffer or cause while participating in this activity, or else I agree to bear the costs

of such injury or damage myself. I further represent that I have no medical or physical condition which could interfere with my safety in this activity, or else I am

willing to assume - and bear the costs of - all risks that may be created, directly or indirectly, by any such condition.

5. In the event that I file a lawsuit, I agree to do so in the state where Releasees’ facility is located, and I further agree that the substantive law of that state shall

apply.

6. I agree that if any portion of this agreement is found to be void or unenforceable, the remaining portions shall remain in full force and effect.

By signing this document, I agree that if I am hurt or my property is damaged during my participation in this activity, then I may be found by a court of law to have

waived my right to maintain a lawsuit against the parties being released on the basis of any claim for negligence.

I have had sufficient time to read this entire document and, should I choose to do so, consult with legal counsel prior to signing. Also, I understand that this activity

might not be made available to me or that the cost to engage in this activity would be significantly greater if I were to choose not to sign this release, and agree that

the opportunity to participate at the stated cost in return for the execution of this release is a reasonable bargain. I have read and understood this document and I

agree to be bound by its terms.

Parent/Guardian Signature ____________________________________________________________________________________________________________ Date _________________________________________

Parent or Guardian Additional Agreement

(Must be completed for participants under the age of 18)

In consideration of ______________________________________________ (PRINT minor’s names) being permitted to participate in this activity, I further agree to indemnify and hold

harmless releasees from any claims alleging negligence which are brought by or on behalf of minor or are in any way connected with such participation by minor.

Parent/Guardian Signature ____________________________________________________________________________________________________________ Date _________________________________________

B.R. RYALL YMCA

| 49 Deicke Dr. | Glen Ellyn, IL 60137 | 630.858.0100 |

of Northwestern DuPage County