Camp Hero Registration 2017

Transcription

1 Camp Hero Registration 2017 Camp Hero my child will be attending: June 5 9 (Joint Base Pearl Harbor Hickam location) June (Marine Corps Base Hawaii location) I would like to register for the Extended Day Version of Camp Hero, **Available ONLY at Joint Base Pearl Harbor Hickam location. 8:00 am 4:30 pm. Childs Name: Age: DOB: Mother/Legal Guardians Name: Mother s Phone: Father/Legal Guardians Name: Father s Phone: Mailing Address: Address: Branch of Service: Rank: Has your child ever attended a Camp Hero program before? What school does your child attend? Registration Fee for Camp Hero 8:00 1:00 pm: $95.00 (E6 and below $65.00) (Additional online registration fee of $6 if registering online) Payment type: Cash Check (Make payable to Armed Services YMCA) Registration Fee for Camp Hero Extended Day Version at JBPHH ONLY 8:00 4:30 pm: $145 (E6 and below $115.00) (Additional online registration fee of $11 if registering online) Payment type: Cash Check (Make payable to Armed Services YMCA)

2 Emergency Contact Information Form Childs name: Age: DOB: Emergency Contacts: (Please provide TWO contacts) Name: Phone number: Name: (other than parent) Phone number: Authorized person(s) to pick up / drop off child: (Please provide TWO contacts) (1) Name Phone Number: (2) Name Phone Number: Primary care clinic: Name of primary care physician: In case of an emergency and I am unable to give verbal consent, I hereby authorize the ASYMCA of Honolulu to refer my child to the nearest emergency room. Signature: Date:

3 Participant s Full Name (Please print clearly) HOLD HARMLESS, WAIVER OF LIABILITY, AND INDEMNITY AGREEMENT For and in consideration of permission granted by the United States Navy and United States Air Force for me to enter Joint Base Pearl Harbor-Hickam (JBPHH) on 7 June 2017, to participate in the ASYMCA sponsored 'In Their Boots Day' and being informed of all the conditions that I will encounter during this period of time, to include, but not limited to, all natural environments, transportation on and off the installation and activities, I forever discharge and hold harmless the Armed Services YMCA of Honolulu, United States of America, United States Navy, United States Air Force, United States Coast Guard, and all of its officers and personnel, employees, representatives, and their successors or assigns, including the Commanding Officer, Joint Base Pearl Harbor Hickam from any and all liability under the Federal Tort Claims Act (28 U.S.C. Sections 1346(b), and ), or other statutes addressing personal injury or property losses. I also waive all claims, demands, damages, actions, or suits of any nature or legal basis against the Armed Services YMCA of Honolulu, United States of America, United States Navy, United States Air Force, United States Coast Guard and their agencies, departments, officers, employees, personnel, and their successors or assigns, including the Commanding Officer, Joint Base Pearl Harbor Hickam, arising from any injury or alleged injury, including death, and property damage or loss that occurs incident to my entering upon, engaging in any activities that are associated with the ASYMCA sponsored 'In Their Boots Day', including, but not limited to, engaging in physical activities, games, static displays, transportation on and off the installation, and/or use of any facility or equipment located on Joint Base Pearl Harbor Hickam wherever the loss or injury may occur. I understand that no special measures have been taken to specifically address the needs, tendencies and care of participants from the ASYMCA sponsored 'In Their Boots Day', during this event. Therefore, I fully appreciate the special risks and understand that I am solely responsible for my care. I understand that this waiver is legally binding on me and my heirs, executors, and administrators. I also acknowledge that I am aware of the risks involved in my duties and responsibilities by participating in the ASYMCA sponsored 'In Their Boots Day'. I further acknowledge that I have carefully read this release, understand the contents thereof, and sign this release as my free and voluntary act. Date Signature of Participant s Parent/Guardian

4 Camp Attending: Child s Name: Parent s Name: Armed Service YMCA Release and Waiver Liability I hereby voluntarily and knowingly assume all risks and dangers inherent and incidental to the activities of Armed Services YMCA programming for myself and my family members. I will not hold the Armed Services YMCA of Honolulu liable for any injuries incurred during programming or in transit to and from the program whether caused by equipment or the act or omissions of others excepting damage or injury solely caused by the willful misconduct or negligence of the Armed Services YMCA of Honolulu, or its employees, volunteers, or agents. I do hereby authorize the Armed Services YMCA of Honolulu as agent for all Armed Services YMCA Members, to consent with respect to the minors, to any, 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 licensed physician and surgeon licensed, whether such diagnosis or treatment is rendered at the office of the physician or at the hospital. I understand that the Armed Services YMCA Honolulu is not responsible for costs incurred for medical care. If I participate in the program, whether as coach, instructor, aide, spectator, or participant, I presently waive as to the Armed Services YMCA of Honolulu and staff, officers and directors thereof, any claim presently known or unknown for damage to property or personal injury whether caused by equipment or the acts or omissions of others including Armed Services YMCA of Honolulu personnel. Parent Signature: Date: Consent to Photograph, Film, or Videotape for Non-Profit Use I hereby grant full permission for myself, my child, and/or my family members to be photographed by the Armed Services YMCA of Honolulu staff for any legitimate purpose without payment or compensation. I also hereby consent to the participation in interviews, the use of quotes, and the taking of photographs, movies, or video tapes. I also grant to the Armed Services YMCA of Honolulu the right to edit, use, and reuse said products for nonprofit purposes including use in print, on the internet, and all other forms of media. I also hereby release the Armed Services YMCA of Honolulu and its agents and employees from all claims, demands, and liabilities whatsoever in connection with the above. By signing below, you acknowledge that your household has received, read, and understood the Armed Service YMCA Release and Waiver Liability and the Consent to Photograph, Film, or Videotape for Non-Profit Use. Parent Signature: Date:

5 Must be completed and stamped by Child s Medical Provider if your child has conditions that may require medical intervention. This form will need to be returned to the Office Manager before your child can be registered. Child s Name Parent Contact Phone # address General Medical Action Plan My Child has NO known medical conditions or allergies that require intervention (if you checked this box you do not need to fill this form out any further. My child has the following conditions that may require medical intervention (please specifyallergies, asthma, etc): The following must be completed and stamped by Child s Medical Provider: Diagnosis: Medicine Name: Dosage: Trigger: Side Effect: When to administer medication: When to repeat medicine: Contact parents and/or emergency services (911), if: Diagnosis: Medicine Name: Dosage: Trigger: Side Effect: When to administer medication: When to repeat medicine: Contact parents and/or emergency services (911), if: Physician s Printed Name: Physician s Signature and Date Physician s Phone Number Page 1 of 2

6 Must be completed and stamped by Child s Medical Provider if your child has conditions that may require medical intervention. This form will need to be returned to the Office Manager before your child can be registered. Child s Name Parent Contact Phone # address Below information to be completed by the parent or guardian I authorize ASYMCA staff to administer the above medications and take the above actions or precautions to my child according to the physician s instructions. I understand that I am responsible for assuring that medication made available to ASYMCA is current (not expired) and I will advise ASYMCA of any changes to this medical action plan. Signature of Parent: Date: Parent/Guardian Authorization of Release of Medical Information: I,, hereby authorize the release of medical information relevant to this medical action form. Signature Date Home Address: Signature of Parent: Date: Page 2 of 2