NAVY CHILD AND YOUTH PROGRAMS REGISTRATION FORM

NAVY CHILD AND YOUTH PROGRAMS REGISTRATION FORM START DATE: REQUIRING DIRECTIVE OPNAVINST 1700.9 NAME OF CHILD (LAST, FIRST, MIDDLE) SEX BIRTHDATE (DD/MM/YY) AGE SPONSORS NAME (LAST, FIRST, MIDDLE) RANK/RATE BRANCH STATUS: ACT RES CIV CTR RET COMCIV HOME ADDRESS (Include City and Zip Code) E-MAIL ADDRESS HOME PHONE CELL PHONE DUTY STATION DUTY PHONE PCS DATE (CIRCLE ONE) SINGLE PARENT DUAL MILITARY FULL-TIME IF SPOUSE IS MILITARY (PLEASE CIRCLE) BRANCH WORKING SPOUSE STUDENT SPOUSE STATUS: ACT RET ENL OFF PART-TIME WORKING SPOUSE UNEMPLOYED SPOUSE SPOUSE S NAME (LAST, FIRST) PLACE OF EMPLOYMENT PHONE NUMBER CELL PHONE RANK/RATE EMERGENCY NOTIFICATION/RELEASE DESIGNEE (other than parents) (minimum of TWO (2) LOCAL REQUIRED) NAME PHONE NUMBER RELATIONSHIP SCHOOL NAME: GRADE: IF NOT, PLEASE SPECIFY: DATE OF LAST MEDICAL EXAM: STATUS GOOD HEALTH ALLERGIES: YES NO IF YES, WHAT? SPECIAL NEEDS: YES NO IF YES, EXPLAIN: SPONSOR AGREEMENT: Field Trip/Transportation Permission: I hereby grant permission for my child to participate in Navy Child and Youth Program (CYP) sponsored field trips. CDC trips may include: walking in the immediate CYP facility area (infants may be transported in a buggy/stroller) or on the military installation. Preschool trips may require bus transportation (CYP or chartered) SAC/YP trips may include: bus transportation (CYP or chartered) to and from schools and field trip locations in the metro area. CYP may also offer planned walks in the CYP facility area and on the military installation. I understand that Navy CYP will provide advance, written notification of each trip outside the immediate area of the facility. Media Release: I hereby grant permission for my child to be included in the use of the following formats for the purpose of education and publicity for the Navy CYP community in perpetuity without further consideration from me: photographs, video, and audio used in the CYP facility media such as: Navy CYP Facebook, military installation website, CNIC CYP website, etc. Topical Non-Prescription Product Application: I hereby grant permission for Navy CYP employees to apply external, topical non-prescription products such as diaper cream, sunscreen, insect repellent, etc. to my child, as needed. If I choose topically applied products that are not supplied by Navy CYP, a Materials Safety Data Sheet will be required for each product. I agree to release and hold harmless the United States, its officers, its agents, and its instrumentalities, against any claims, demands, actions, debts, liabilities, judgments, costs, or attorney's fees arising out of, claimed on account of, or in any manner predicated upon his/her participation in any Navy MWR/CYP activity, use of facilities and/or equipment including any loss or damage to property, any injury or death of any person, in any manner, caused or contributed to by the United States, its officers, its agents, or its instrumentalities. I have received a copy of and understand the policies contained in the Navy CYP Parent Handbook. Additionally, I understand that I may revoke/invoke any of the above permissions in writing at any time. I HEREBY GIVE MY CONSENT FOR AN AUTHORIZED CHILD AND YOUTH PROGRAM (CYP) REPRESENTATIVE TO CALL AN AMBULANCE FOR MY CHILD,, ONLY FOR CARE (MEDICAL OR DENTAL) IN AN EMERGENCY SITUATION. I UNDERSTAND THAT A CONSCIENTIOUS EFFORT WILL BE MADE TO NOTIFY ME OR MY EMERGENCY DESIGNEES PRIOR TO SUCH ACTION. ANY EXPENSE INCURRED WILL BE BORNE BY ME AND TREATMENT MAY TAKE PLACE AT ANY MEDICAL FACILITY. NAME OF CHILD S MEDICAL INSURANCE COMPANY: POLICY NUMBER: NAME OF INSURED: SPONSOR SIGNATURE DATE CYP REPRESENTATIVE SIGNATURE DATE PRIVACY ACT STATEMENT: AUTHORITY: P.L. 101-89, Sec, 1507, Military Child Care Act of 1989 ; Title 5 U.S.C. 301 Department Regulations; E.O. 9397; and OPNAVINST 1700.9 Child and Youth Programs. PURPOSE: To provide Child and Youth Programs (CYP) with authorization for medical treatment in emergency situations; identify children and sponsors; record required immunizations; and record known allergies and special instructions. ROUTINE USES: Information may be furnished to military or civilian doctors or hospitals in the course of obtaining medical attention for children. The SSN is necessary so that the Child and Youth Programs can identify the individual and his/her records. Information furnished may be disclosed to any DoD component, and upon request, to other federal, state and local governmental agencies in the pursuit of their official duties relating to proper child care. Finally, the information may be disclosed to law enforcement activities for the purpose of litigation. VOLUNTARY DISCLOSURE: Furnishing the information is voluntary; however, failure to provide the requested information could result in denial of a child s admission to the CYP. CNICCYP 1700/04 (Rev 09-12) For Official Use Only Privacy Sensitive

INSTRUCTIONS FOR CHILD AND YOUTH PROGRAMS (CYP) REGISTRATION FORM A separate form shall be completed for each child registered. The parent shall complete all the information about the family and/or child. STATUS BLOCK: Circle any area(s) that apply to the status of sponsoring parent (ACT - Active Duty, RET - Retired, RES - Reservist, CIV - DoD Civilian, CTR - DoD Contractor, COM CIV - Community Civilian. After completing the form, parent(s) must sign and date in the SPONSOR AGREEMENT section. This signature and date verifies that all information is correct and validates the agreement to allow transport for medical or other emergencies. At least annually or when the information is outdated, a new form will be completed, signed, and dated. A CYP representative (e.g., clerk, director, provider, etc.) will sign and date in SPONSOR AGREEMENT box as witness to the parent s signature and date. The original Navy CYP Registration Form (CNICCYP 1700/04) shall be kept in the CYP Child Registration Form File. This file shall be maintained in an easily accessible file and shall be taken outside with the day s sign-in sheet during an evacuation drill or in the event of an emergency. A copy shall be maintained in the child administration file shall be maintained at the front desk administrative area in a locked file cabinet or locked file box. Programs using CYMS are NOT required to maintain a separate copy in the child s administration file; however, all information must be kept current in CYMS. CHILD DEVELOPMENT HOME PROGRAMS: CDH providers shall maintain the original CYP Registration Form for each child in the home. Forms shall be in an easily accessible location for emergency contact or evacuation. The CDH office shall maintain an alphabetized current copy of each child s Navy CYP Registration Form for each child enrolled. Forms shall be in an easily accessible location (for the telephone or for evacuation). FOR ALL PROGRAMS: Registration forms, with the sign-in sheet, shall be taken outside during an evacuation drill or in the event of an emergency. A duplicate copy of each child s Navy CYP Registration Form, with local emergency contact numbers/names must be taken on each field trip. CNICCYP 1700/04 (Rev 09-12) For Official Use Only Privacy Sensitive

SUBASE NLON CYP PROGRAM PROTECTION OF THE RIGHTS OF CHILDREN, YOUTH, & THEIR FAMILIES Subase NLON Child & Youth Programs are committed to ensuring the rights and privacy of children, youth, and their family members are respected. 1. All children, youth, and their families are to be treated in a non-discriminatory manner, regardless of race, color, national origin, religion, sex, age, or abilities. 2. A grievance system is available for children, youth & their families to express and resolve their program concerns without fear of interference or retaliation. 3. The program accommodates the written and oral communication needs of the children, youth and families by ensuring program materials are available in the languages of the major populations we serve. 4. The program will, to the extent possible, provide communication assistance to those who need translation, are deaf or hearing impaired, have special needs, or need assistance due to their literacy level. 5. The program ensures informed, written consent is obtained from children, youth and their families prior to recording, photographing, or filming. 6. All information on children, youth and their families is maintained and kept confidential according to Privacy Act guidelines. 7. When the program receives a third party request for confidential information, it will determine if the reason to release the information is valid; obtain informed, written authorization from the parent or legal guardian; offer a copy of the signed authorization to the parent or legal guardian; and maintain a copy in the children s file. The Freedom of Information Act and the Privacy Act apply to all requests for confidential information. 8. Circumstances may arise when the program is legally permitted or required to disclose confidential or private information without consent of parents or guardians. In these cases, the program will seek the counsel of the Staff Judge Advocate prior to the release of any information. This may include release to law enforcement agencies, Department of Children & Families, and Mental Health Services; this list is not exclusive. The Freedom of Information Act and the Privacy Act apply to all requests for confidential information. C A TERRALL YOUTH DIRECTOR

Child and Youth Behavioral Military and Family Life Consultant (MFLC) Program Due to the unique challenges faced by military families the DoD offers the Child and Youth Behavioral MFLC program. It is a private and confidential non-medical counseling service available to service members, dependents and staff of the Child and Youth Programs, DoD Education Activity Schools and summer programs, local education agencies, and a variety other military programs for children and families. The MFLC may support staff and work with children and families in the following ways: Observe, participate, and engage in activities with children and youth Provide direct intervention with children Model behavioral management techniques and provide feedback to staff Suggest courses of age-appropriate behavioral interventions to enhance coping and behavioral skills Outreach to parents Facilitate psycho-educational groups Conduct training for staff and parents (using materials approved by the DoD only) Recommend referrals to military social services and other resources as needed The MFLC may assist parents, teachers, staff, and children with the following issues Communication Resolving conflicts Managing anger Bullying Self-esteem/self-confidence Behavioral management techniques Sibling/parental relationships Deployment and reintegration issue The consultant is available to accommodate appointments and meetings/activities after hours and on the weekend with advance notice. At no time will the consultant meet individually with a child without being in line of sight of CYP employee, DoDEA, LEA, or parent/guardian. The MFLC can be reached at the following numbers: 860-448-6838 or 860-448-6843. Cathy Terrall is the CYP point of contact for the CYB-MLFC. She can be reached at 860-448-6843.

I acknowledge that a CYB-MFLC is available and authorize my child to receive this support. Sponsor/Parent/Guardian Signature Date I acknowledge that a CYB-MFLC is available but do not authorize my child support. to receive this Sponsor/Parent/Guardian Signature Date

IMPORTANT: THIS IS A LEGAL DOCUMENT Please read and understand this document before signing. If you have any questions please ask us or consult an attorney. Navy Morale, Welfare and Recreation (MWR) Department Naval Submarine Base New London, Navy Child & Youth Programs (CYP) and its staff have done everything possible to assure that our patrons experience a rewarding experience. We wish to inform our patrons that participating in sports are not risk free. The same elements that contribute to the unique character and fun of sports such as physical exertion or the terrain can cause loss or damage to equipment, and injury, illness, or in extreme cases, permanent trauma or death to the participant or others under his or her supervision. We do not want to heighten or reduce your enthusiasm for the experience, but we do want you to know in advance what to expect, and to be informed of some of the possible risks. We ask that you read this, sign it, and return it to our office. ACKNOWLEDGMENT OF RISK I (name of participant) hereby acknowledges that I have voluntarily chosen to participate in the Navy MWR/CYP Youth Judo Program (hereinafter called program ) through Navy MWR Naval Submarine Base New London. I am participating in the program with the knowledge of the risks involved and hereby agree to accept any and all inherent risks including, but not limited to temporary or permanent muscle soreness; sprains; strains; cuts; abrasions; bruises; ligament and/or cartilage damage; head; neck or spinal injuries; loss of use of arms and/or legs; eye damage; disfigurement; or even death. I also recognize that there are both foreseeable and unforeseeable risks of injury that may occur as a result of participating is this program. Furthermore, I recognize that participation in the program involves activities and risks incidental thereto, including but not limited to, travel to and from competitions, practices, and other related activities, limited availability of medical assistance and the possible reckless conduct of other participants. This list is not an exclusive or exhaustive list of possible injuries, trauma, or accidents that may occur participating in this program. Most of these injuries are rare and you are not likely to encounter them. However, they have occurred, and you need to know about them and other possible injuries not mentioned above. These injuries occur more often when the participants are not physically able to undertake these activities. CONTRACT, WAIVER, RELEASE AND INDEMNIFICATION I certify that I am fully capable of participating in the Navy MWR Sports Program at Naval Submarine Base New London. I state that I have read the above statement on some of the possible risks associated with participating in the Navy MWR Sports Program. Therefore, I assume full responsibility for myself, for bodily injury, death and loss of personal property and any expenses as a result of my negligence or the negligence of Navy MWR Department SUBASE NLON. and its staff. I also understand that Navy MWR Department Naval Submarine Base New London reserves the right to refuse any person it judges to be incapable of meeting the rigors and requirements of using this facility. I agree to indemnify and hold harmless Navy MWR, Navy MWR Department Naval Submarine Base New London, and its staff, and the U.S. Navy, and its members, agents and employees from all claims, damages, losses, injuries and expenses arising out of or resulting from my participation in this program. I further agree to release, acquit and covenant not to sue Navy MWR, Navy MWR Department Naval Submarine Base New London, Naval Submarine Base New London and its staff, and the U.S. Navy, and its members, agents and employees for all actions, causes of action claims or damages, damages in law or remedies in equity of whatever kind, including the negligence of Navy MWR Department Naval Submarine Base New London and its staff or my family, myself, or my heirs, against Navy MWR Department Naval Submarine Base New London arising out

of participation in this program. In short, I cannot sue Navy MWR, Navy MWR Department Naval Submarine Base New London Naval Submarine Base New London and its staff, and the U.S. Navy, and its members, agents and employees, and if I do, I cannot collect any money. I agree to the site of any lawsuit and the law governing any such lawsuit shall be governed under the Federal Tort Claims Act, Military Claims Act, Foreign Claims Act, Suits in Admiralty Act, Public Vessels Act or Admiralty Extension Act, which ever is applicable. As liquidated damages, I hereby agree that if Navy MWR Department Naval Submarine Base New London is forced to defend any action, lawsuit or litigation by myself, my executors, or my heirs, on my family's or my behalf; accordingly, my heirs or executors and I agree to pay court costs and attorney fees if they successfully defend such action, lawsuit or litigation. Should any paragraph or part of this agreement be declared unenforceable by a court of competent jurisdiction, the remaining parts or paragraphs shall remain in full force and effect. A copy of this release can be used as if it was an original. I authorize and release to Navy MWR Department Naval Submarine Base New London and its staff the use of my image in any photograph or video recording for any purpose of Navy MWR Department Naval Submarine Base New London I have adequate health, disability and life insurance for my family and myself. I hereby give permission for transportation to any medical facility or hospital, and I authorize for any guide, or medical personnel to render necessary emergency medical care for my family or me. I hereby authorize the release of any medical information, including information concerning my HIV or AIDS status, in the possession of Navy MWR Department Naval Submarine Base New London to any medical facility, hospital, ambulance, first aid provider, first aid service, doctor, nurse or other such person rendering care on my behalf. I hereby waive any action or claim against Navy MWR Department Naval Submarine Base New London and its staff or any health care provider, hospital, doctor, nurse, or first aid provider for the release of this medical information including my HIV or AIDS status. I,, of my own free will, for my family, my minor children, my heirs and executors and myself, have read, understand and acknowledge the risks and liability for myself, and my family this day of 2011. [ ] I affirm that I am of lawful age and legally competent to sign this waiver, or that I have acquired the written consent of my parent or guardian. I have read and understood this agreement. PARTICIPANT SIGNATURE PRINT NAME PHONE: [ ] IN CASE OF EMERGENCY PLEASE CONTACT: PHONE: I CARRY MEDICAL INSURANCE. YES NO GROUP NUMBER: NAME OF PROVIDER: