Medical Review And Informed Consent Form - Ymca Camp Menogyn printable pdf download

YMCA Camp Menogyn

Medical Review and Informed Consent

*Please have everyone in your group sign, if under 18, the guardian must sign*

Name: ____________________________________________ Group Name: _____________________________

Home Phone: ______________________________________ Date of Program: ___________________________

Home Address: ____________________________ City: ________________________ State: ____ Zip: ______

In an Emergency Notify: ______________________________________ Relationship: _____________________

Home Ph: ______________________ Cell Ph: ________________________ Work Ph: ___________________

YMCA Camp Menogyn spends most of the time outdoors. As a result, participants take certain risks due to weather conditions,

natural hazards, and/or physical infirmities. The YMCA takes precautions to follow rigorous safety procedures, but the risks cannot

be totally eliminated. Please answer all of the following questions. Participation in this program is voluntary and you can decline

participation in all, or any part of, the activities occurring during this program.

Has a physician told you or are you aware of any medical conditions that could be aggravated by physical activity, such as: heart

disease, high blood pressure, lung disease, diabetes, pregnancy or others?

______Yes

______No

Has a physician told you or are you aware of any problems with your neck, back, shoulders, wrist, hips, ankles, or knees that may be

aggravated by physical activity?

______Yes

______No

Has a physician told you or are you aware of any problems with life threatening allergic reactions that may be aggravated by physical

and/or outside activity?

______Yes

______No

Has a physician told you or are you aware of any problems with seizures that may be aggravated by physical activity?

______Yes

______No

Has a physician told you or are you aware of other physical problems, which you think we should know about before activities begin?

______Yes

______No

If you answered yes to any of the conditions above, please name the condition and give a detailed description below (including dates

and restrictions, if any).

The information provided here is a complete and accurate statement of the physical factors, which may effect my participation in the

YMCA Camp Menogyn. I have decided to voluntarily participate in this program, or segments of the program, and in consideration of

the YMCA Camp Menogyn accepting me into this program, I hereby waive and release all rights and claims which I may have against

YMCA Camp Menogyn, its employees and its agents for any and all injuries and damages suffered by me in participating in this

program. This release does not, however, apply to injuries or damages caused by the gross negligence or willful misconduct by

YMCA Camp Menogyn, its employees or its agents. I agree to hold YMCA Camp Menogyn, its employees and its agents harmless if

all relevant information is not disclosed. This information will be kept confidential except in the case of emergency. In case of

emergency, this consent includes the release of medical and accident report forms to insurance companies, my employer, or any other

agency deemed appropriate by YMCA Camp Menogyn.

SIGNED: ____________________________________________________________________ DATE: ___________________

Medical Review And Informed Consent Form - Ymca Camp Menogyn