Martinsville-Henry County Family Ymca 2015-2016 School Year Form (Page 4 of 7) in pdf

Last Name of Child

First Name of Child

SWIMMING SKILLS

Can your child swim? □yes

□no

Can your child swim in water above his/her head without a floatation device? □yes

□no

Please mark one of the following boxes:

□ I give permission for my child to swim

□ I DO NOT want my child to swim

MEDIA COVERAGE

Occasionally pictures of the children attending YMCA Child Care Programs may appear in newspaper

articles or media publications concerning special events at the school, community events etc.

Please mark on of the following boxes:

□ I give permission for my child’s picture to appear in the media

□ I DO NOT wish for my child’s picture to appear in the media

Approval and Release of Liability

I am the parent/guardian of the above named child and give my permission for the child to participate

in the YMCA Child Care Program and it’s activities which may include (but are not limited to) outdoor

play, sports skills, swimming, and weekly field trips. I give my permission for the child to ride the YMCA

bus to and from field trips.

I hereby release the Family YMCA of Martinsville & Henry Co., and all establishments where field trips

are conducted, including but not limited to the Family YMCA of Martinsville & Henry Co., from any

responsibility or liability for injury to the above named child, while participating in a YMCA program. In

authorizing this, I acknowledge that I am aware of the risks and that I have adequate insurance to

protect my child in the event of an injury. I understand that this authorization to allow my child to

participate in YMCA programs, is a waiver of all claims that I, my child, or other family members, or my

insurance carrier would have against the Family YMCA of Martinsville & Henry Co., its board,

employees, program leaders, or volunteers. The YMCA agrees to notify the parent/guardian whenever

the child becomes ill and the parent/guardian must arrange to have the child picked up as soon as

possible. Parent/guardian must also inform the YMCA within 24 hours if any member of the immediate

household develops any reportable communicable disease, as defined by the State Board of Health.

EMERGENCY AUTHORIZATION: I hereby give permission to the medical personnel selected by the

YMCA to order X-rays, routine tests and treatment for my child, and in the event that I cannot be

reached in an emergency, I hereby give permission to the physician selected by the YMCA to

hospitalize, secure proper treatment for, and order injection and/or anesthesia and/or surgery for my

child named above. This form may be photocopied.

Signature of Parent or Legal Guardian

Date

PARENT OR GUARDIAN MUST READ, INITIAL, AND COMPLY WITH EACH OF THE

FOLLOWING:

I understand that I am fully responsible for reading the Parent Handbook,

Payment Contract and Payment Policy.

I am aware of my financial obligations to the YMCA according to the Payment Contract.

I understand that my child can be terminated from the program without warning for any

type of violent behavior (see parent handbook for Discipline Policy) and/or parents failure to

make weekly payments.

I understand that I have to pay the non-refundable $25.00 registration fee before my child is

considered registered for this program.

Martinsville-Henry County Family Ymca 2015-2016 School Year Form Page 4

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