Liability Waiver / Cyss Youth Program Registration & Sponsor Consent
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3"PRIVACY" "Privacy Act of 1974" "This document conforms to the privacy act of 1974: 10 USC 30 31."
LIABILITY WAIVER
Print Date:
Household #:
USAG Kwajalein CYS
Hm Ph: (805)355-2084
P O Box 51
701 P.O. Box
Wk Ph: (805)355-3601
APO AP 96555
APO AP 96555
Phone: (805)355-2158
Participant: ______________________
Guardian: _______________________
MEMORANDUM FOR RECORD
SUBJECT: Child and Youth Services (CYS) Statements of Understanding and Medical Consent
Statement
1. Data Required by the Privacy Act of 1974
2. Authority. Title 10, United States Code, section 3012.
3. Principal Purpose. Information is used by DA personnel to: (1) provide Child and Family program
eligibility and background information, (2) develop programs meeting needs of Children and Families, (3)
ensure appropriate placement of Child, (4) identify contingency plan for Child illness, (5) identify
emergency designees.
4. Routine Uses. Information on immunization and medical problems will be used as part of the program
admission screening procedure. Family income data will be used to determine USDA food program
qualification and rate structures. Medical consent information is furnished to the attending physician when
it is necessary for a child to be taken to a medical facility by someone other than the parent.
5. Disclosure. Disclosure of requested information is voluntary. However, if information is not provided,
individuals may not be allowed to participate in Child and Youth Services (CYS) programs.
6. Statements of Understanding.
a. I have received the CYS Parent Handbook and will abide by all policies.
b. I have reviewed the Household and Family information file. To the best of my knowledge, the
information provided to CYS is accurate and complete.
c. I acknowledge that CYS is facilities are under video surveillance.
7. Medical Consent Statement.
a. I give consent by signing this agreement, for an authorized Child and Youth Services (CYS)
representative to take my Child for care, medical or dental, in an emergency situation when the child's
condition represents a serious or imminent threat to his/her life, health, or well-being.
b. I understand that a conscientious effort will be made to notify me before such action.
c. I will pay any expenses incurred.
d. Treatment at an Army medical facility may be provided without additional consent under provision of
AR 40-3, paragraph 2-24b.
_____________________________________
___________________
PARENT/GUARDIAN SIGNATURE
DATE
F:\Admin\Teen Center Registration Packets\TEEN CENTER WAIVER & REGISTRATION FORMS
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