Consent/release Form - Safe 'N Sound printable pdf download

CONSENT/RELEASE FORM

SAFE ‘N SOUND

Emergency Care

I hereby authorize the staff of the Safe ‘n Sound program of the B.R. Ryall YMCA to secure emergency medical

care for my child ___________________________________________________________________ when I cannot be immediately reached at

the time of emergency. I will be responsible for the emergency medical charges upon receipt of the statement.

_____________________________________________________________________________ is our preferred doctor/clinic/hospital. Please advise medical

personnel that I carry the following medical insurance plan: _____________________________________________________________________________,

policy #__________________________________________________________________.

Signature of Parent/Guardian _________________________________________________________________________________________

Date __________________

Child’s Doctor ____________________________________________________________________________________ Phone _________________________________________

Emergency First Aid

The only first aid measures offered at the program are as follows: Bump or bruise - apply ice as needed; cut or scratch -

clean with soap and water, bandage; nose bleed - apply pressure. If further care is needed, we will notify a parent/guardian.

Signature of Parent/Guardian _________________________________________________________________________________________

Date __________________

Transportation, Trips, Excursions and Public Park Facilities

I authorize my child to ride as a passenger in the vehicles owned by the B.R. Ryall YMCA for the purpose of transportation

to and from school, short trips and excursions. I also authorize the representatives of the Safe ‘n Sound before- and after-

school program of the B.R. Ryall YMCA to take my child on walking trips, special excursions, and to nearby park facilities.

I understand that all such trips are under the supervision of YMCA staff members and that health and safety precautions

are taken. Staff will always notify parents before taking such a trip.

Signature of Parent/Guardian _________________________________________________________________________________________

Date __________________

Photographs and Video

I authorize that the B.R. Ryall YMCA has my permission to photograph or videotape my/our child for purposes of program

promotion or publicity.

Signature of Parent/Guardian _______________________________________________________________________________________ Date ____________________

B.R. RYALL YMCA

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

of Northwestern DuPage County

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Consent/release Form - Safe 'N Sound