Youth Medical Release Form Magdalena Ecke Family Ymca printable pdf download

MAGDALENA ECKE FAMILY YMCA

200 SAXONY ROAD

YOUTH MEDICAL RELEASE FORM

ENCINITAS, CA 92024

FAX: 760.944.9329

IMPORTANT • THIS FORM MUST BE COMPLETED ANNUALLY. It can be dropped at the Registration Desk during regular business hours, mailed

to the Magdalena Ecke Family YMCA, Attn: Registration Department, 200 Saxony Road, Encinitas, CA 92024; or faxed to 760.944.9329, Attn:

CHILD’S INFORMATION

Registration Department. It must be received at the Magdalena Ecke Family YMCA prior to the start of all classes, programs or camps.

CHILD’S NAME:

BIRTH DATE:

AGE

MALE { }

FEMALE { }

HOME PHONE:

HOME ADDRESS:

PARENT 1 NAME:

CELL PHONE:

EMAIL:

PARENT 2 NAME:

CELL PHONE:

EMAIL:

GUARDIAN’S NAME:

CELL PHONE:

EMAIL:

CHILD RELEASE AUTHORIZATION

Persons authorized to pick-up child from facility

1 NAME:

RELATIONSHIP

PHONE 1:

PHONE 2:

2 NAME:

RELATIONSHIP

PHONE 1:

PHONE 2:

3 NAME:

RELATIONSHIP

PHONE 1:

PHONE 2:

PERSONS UNAUTHORIZED | Persons NOT authorized to pick-up child

1 NAME:

RELATIONSHIP

PHONE:

PHONE 2:

2 NAME:

RELATIONSHIP

PHONE:

PHONE 2:

HEALTH INFORMATION

REQUIRED BY STATE LAW

HEALTH INSURANCE CO.:

POLICY #

DOCTOR’S NAME:

PHONE #

DENTIST’S NAME:

PHONE #

ARE YOUR IMMUNIZATION RECORDS UP TO DATE?

YES { } | NO { }

TETANUS SHOT DATE NEEDED:

LIST ALLERGIES, SERIOUS INJURIES, DISEASES, OPERATIONS AND

IS THIS CHILD CURRENTLY TAKING

YES { }

NO { }

ANY RESTRICTIONS ON PHYSICAL ACTIVITY:

ANY MEDICATIONS?

_________________________________________________________________________________________________________

THERE IS A SEPARATE FORM REQUIRED FOR MEDICATION TAKEN DURING CAMP.

THAT FORM IS AVAILABLE FROM THE CAMP UNIT LEADER OR FROM THE FRONT DESK.

_________________________________________________________________________________________________________

LIST ANY CONDITIONS REQUIRING SPECIAL CONSIDERATION, ACCOMMODATIONS:

LIST ANY PAST TREATMENT THAT MAY AFFECT PARTICIPATION IN CAMP:

_________________________________________________________________________________________________________

__________________________________________________________________________________________________

_________________________________________________________________________________________________________

__________________________________________________________________________________________________

LIST ANY ACTIVITIES FROM WHICH THE CAMPER SHOULD BE EXEMPTED FOR

YMCA OF SAN DIEGO COUNTY MEMBER/PARTICIPANT ETHNICITY TRACKING TOOL:

HEALTH REASONS:

(OPTIONAL) THIS VOLUNTARY INFORMATION WILL BE USED FOR STATISTICAL

PURPOSES IN ORDER TO ENABLE OUR YMCA TO PROVIDE QUALITY SERVICES

TO OUR COMMUNITY?

_________________________________________________________________________________________________________

{ } WHITE/CAUCASIAN

{ ) NATIVE AMERICAN INDIAN

{ } BLACK/AFRICAN AMERICAN

{ } HISPANIC/LATINO

{ } ASIAN/PACIFIC ISLANDER

{ } MULTI-CULTURAL

_________________________________________________________________________________________________________

PRIMARY LANGUAGE:

{ } ENGLISH

{ } SPANISH

{ } OTHER _______________________________________________

I, the undersigned parent/person having legal custody/guardianship of the above said minor, give permission for the minor to participate in all YMCA programs. The minor is

physically able and mentally prepared to participate in all activities as described in the announcement for the program.

In consideration of said minor being permitted to enter any branch of the YMCA of San Diego County (“YMCA”) for observation, use of facilities and/or equipment, or

participation in any program, I, on behalf of myself (as parent, guardian, coach, aide, spectator or participant) hereby:

1. Acknowledge that (i) I have read this document, (ii) I have inspected the YMCA facilities and equipment, (iii) I accept them as being safe and reasonably suited for the

purposes intended and (iv) I voluntarily sign this document.

2. Release the YMCA, its directors, officers, employees and volunteers (collectively “Releasees”) from all liability to me for any loss or damage to property or injury or death

to person, whether caused by Releasees or otherwise and while such minor is in or near any YMCA branch.

3. I agree not to sue Releasees for any loss, damage, injury or death described above and I will indemnify and hold harmless Releasees and each of them from any loss,

liability, damage or cost they may incur due to said minor’s presence In, upon or near the YMCAs branch: whether caused by the negligence of Releasees or otherwise.

4. I assume full responsibility for, and risk of, bodily injury, death or property damage due to the negligence of Releasees or otherwise.

5. I do hereby authorize the YMCA as agent for the undersigned, to consent with respect to said minor, to any x-ray examination, anesthetic, medical, dental, or surgical

diagnosis or treatment, and hospital care which is deemed advisable by and is to be rendered under general or special supervision of, any physician and surgeon licensed

under the provisions of the California Medical Practice Act on the medical staff of any hospital, whether such diagnosis or treatment is rendered at the office of the

physician oral the hospital. I understand that the YMCA is not responsible for costs incurred for medical care.

6. I have read and agree to the Magdalena Ecke Family YMCA credit and refund policies.

7. I give the YMCA of San Diego county permission to use any picture or likeness of me, or a picture or likeness of my children, in the YMCA’s general publicity and campaign

materials.

I intend this document to be as broad and inclusive as is permitted by the laws of the State of California: if any portion hereof is held invalid, I agree the balance shall continue

in full force and effect.

_______________________________________________________________________________________

__________________________________________________________________________

________________________________

PARENT/GUARDIAN SIGNATURE:

PRINT NAME:

DATE: