Ymca Of Metro Atlanta Emergency Information, Waiver, And Medical Authorization Form printable pdf download

YMCA OF METRO ATLANTA EMERGENCY INFORMATION, WAIVER, AND MEDICAL AUTHORIZATION FORM

Updated 3.20.12

Print Parent/Guardian Name: _______________________________________________________ Date _________________________

Child’s Information:

Complete one form for each child.

First Name: ___________________________________ Last Name: _______________________________ ___ Age: _____________

Yes

Birth Date: ___________ _________

Male

Female

Are immunizations current?

Has child been hospitalized or had operations, serious injuries, fractures, etc. in the past five years?

Yes

Does he/she have any disability, special needs, chronic or recurring illness or conditions?

Yes

Does he/she have any conditions requiring medical, treatment or special considerations while in this program?

Yes

Are there any activities from which your child should be exempted for health reasons?

Name current medications (perscribed or over the counter) and give instructions: __________________________________________

__________________________________________________________________________________________________________

List allergies and diet restrictions: ________________________________________________________________________________

If you anwered YES to any of the questions above, please give details: __________________________________________________________________

_______________________________ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _________________________ _ _ _____________________________________________________________

Health Insurance Information:

Physician’s Name: ______________________________________________ at (hospital/clinic/office): ______________________________

Phone Number: _______________ _ ____ _ _ _ ___________________ _ _ Medical Insurance Carrier: ____________________________________

Policy Number: _______________ _ _____________________ Group Number: _______________________ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _____

Initial Emergency Contact:

Parent/Guardian to be contacted first: _____________________________________________ Phone: ____________ ______________

If the initial emergency contact cannot be reached, we will attempt to reach (Please include at least one relative and one available

neighbor):

Name: _________________________________________ Relationship: _________________ Phone: __________________________

Parent/Guardian Authorization:

I certify that, in advance of participation in YMCA programs, I have received any and all information which I deem necessary or impor-

tant in making an informed choice regarding my child/ward’s participation in such activity or program. I acknowledge the risks inher-

ent in my child’s participation in activities. In consideration for the Metro Atlanta YMCA, allowing my child/ward to participate in such

activity or program, I hereby voluntarily agree to assume all risks of his/her participation in such activity or program. I understand that

the YMCA day camp program is not licensed and is not required to be licensed by the State. The YMCA has been granted an exemption

from licensing by the Department of Early Care and Learning.

IN EXCHANGE FOR ALLOWING MY CHILD/WARD TO PARTICIPATE IN YMCA PROGRAMS AND SERVICES, I HEREBY AGREE TO

RELEASE AND HOLD HARMLESS the YMCA, its employees, officers, directors and volunteers, from any loss, liability, claim of bodily

injury or death or property damage, or costs which may arise due to my use of the YMCA’s facilities and equipment and my participa-

tion in YMCA programs, including claims arising out of negligence of the YMCA and its employees and volunteers. The use of all YMCA

facilities shall be undertaken at the undersigned’s own risk. This agreement shall be governed by the laws of Georgia. I give permission

for my child/ward to participate on supervised field trips away from the site. The health information about my child that I have provided

to the YMCA (including my child’s immunization records) is complete and correct so far as I know. My child has permission to engage

in all prescribed activities except as noted in his/her registration materials.

Authorization of Treatment:

I hereby give my permission to the medical personnel selected by the director to secure emergency medical treatment including but

not limited to, first aid, CPR, admission to any hospital, tests, surgery or general anesthesia, so long as care is provided by persons

or facilities licensed in the state in which such treatment is rendered. In the event I cannot be reached in an emergency, I hereby give

permission to the physician selected by the director to secure and administer treatment, including hospitalization, for the child named

above. The completed forms may be photocopied for field trips. I further acknowledge that any medical treatment ordered is my finan-

cial responsibility and not that of Metro Atlanta YMCA, or any of its agents, volunteers or employees.

Hospital Consent:

Hospital has permission to treat my child (specify name of hospital): ____________________________________________________

Acknowledgement of Policies & Guidelines

By signing below, I acknowledge that I have read the above information, and that I understand the policies and guidelines of the

program and I agree to abide by them. Should I have any questions or concerns, I will contact the Program Director. I understand that

the staff makes every effort to provide a quality program, but additionally it is important that participants and parents follow all rules,

guidelines and procedures in order for the program to be a successful experience for all.

Signature of Parent/Guardian: ___________________________________________________ Date: _____________________________

Ymca Of Metro Atlanta Emergency Information, Waiver, And Medical Authorization Form

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