CAMPER IN LEADERSHIP TRAINING (CILT) REGISTRATION

Transcription

1 CAMPER IN LEADERSHIP TRAINING (CILT) REGISTRATION Please circle the CILT program that you are interested in applying for: *Downtown *Camp Thunderbird *Chester *Chickahominy *Goochland *Midlothian *Northside *Patrick Henry *Petersburg *Shady Grove *Swift Creek *Tuckahoe Child s Information: Child s Full Name (Last, First, Middle) Preferred Name City State Zip Home Phone Gender Male Female School Grade Age Date of Birth T-Shirt Size (please circle): YL Small Medium Large XLge XXLge Custodial Guardian Information: In the event of an emergency, please number, in order of priority (1 6), which phone to contact. Parent / Guardian s Name Cell Phone Priority City State Zip Home Phone Priority Place of Employment Work Phone Priority Parent / Guardian s Name Cell Phone Priority City State Zip Home Phone Priority Place of Employment Work Phone Priority Emergency Contact Names, es and Phone Numbers of TWO LOCAL ADULTS to be called in the event that we cannot reach either guardian: Emergency Contact Name Primary Phone City State Zip Alternate Phone Emergency Contact Name Primary Phone City State Zip Alternate Phone

2 Additional Information: Are there any allergies, intolerance to food, medication, and any other substances? What are the symptoms and action to be taken, if any? To ensure the best possible experience, tell us about any emotional, behavioral, physical or developmental challenges and any special accommodations needed. My child's swimming level is: Beginner Intermediate Advanced Doctor s Name Doctor s Phone Medical Insurance Provider Policy # (es), for registration confirmation, fliers, newsletters, invoices and all other communications (other than the occasional phone call) address(es) The following Statements of Understanding and Authorization, Releases and Agreements are important for the safety and protection of each child. Please read this information and sign at the bottom. STATEMENT OF UNDERSTANDING 1. I understand that there is a program fee for each CILT session. A $240 Program Fee for Y Members and a $265 Program Fee for Non-Members in addition to a $25 Registration Fee that is due at the time of registration. 2. For safety reasons, it is extremely important to be able to reach the parent(s)/guardian(s) or emergency contact(s) for a child in our program. I understand that I need to update personal information as changes occur. 3. I understand that YMCA staff and volunteers are prohibited from babysitting at any time outside of the YMCA facilities or program(s) children with whom their only relationship is through YMCA programs or transporting these children in their personal vehicles. STATEMENT OF AUTHORIZATION 1. My child has permission to be transported by a YMCA vehicle and to participate in all YMCA CILT program activities, association events and training opportunities. 2. I give the YMCA of Greater Richmond permission for my child to be given cardiopulmonary resuscitation (CPR) and first aid treatment by a qualified staff member of the YMCA of Greater Richmond. I also give permission for my child to be transported by ambulance or aid car to an emergency center for treatment. I authorize the YMCA of Greater Richmond to obtain immediate medical care and give consent to the hospitalization and performance of necessary diagnostic test upon, the use of surgery on, and/or the administration of drugs to his/her child or ward if an emergency occurs when he/she cannot be located immediately. It is also understood that this agreement may cover only those situations which are true emergencies and only when he/she cannot be reached. I understand that the provider will take every effort to contact me and/or my designated emergency contacts. I understand that I will be responsible for payment of medical expenses. MEDICATION AUTHORIZATION 1. I authorize staff to administer over-the-counter medication to my child. Yes No 2. I authorize staff to administer prescription medication to my child. Yes No PHOTO AND VIDEO RELEASE The YMCA of Greater Richmond requires your consent for the use of photographs or digital images of your child in any printed/filmed material for promotions. Please check below to indicate whether you give the YMCA of Greater Richmond consent or not. Note: If this selection is left blank, Yes will be selected for you. I consent to authorize the YMCA of Greater Richmond to use photographs or digital images in any printed/filmed material for promotions. Yes No

3 CHALLENGE COURSE AGREEMENT Children in Camp programs have the potential to enjoy a challenge course experience at three of our local facilities: Camp Thunderbird, Shady Grove and Tuckahoe. As a result, we require that all Camp participants acknowledge and agree to the following. I HEREBY ACKNOWLEDGE AND AGREE on behalf of my child that the use of the Challenge Courses have inherent risks. I have full knowledge of the nature and extent of all the risks associated with the use of the Challenge Courses, including but not limited to: 1. All manner of injury resulting in falling off the Challenge Courses; 2. Rope abrasion, entanglement and other injuries resulting from activities on or near the Challenge Courses such as, but not limited to, climbing, belaying, rappelling, lowering on rope, rescue systems, and any other rope techniques; 3. Injuries resulting from falling climbers or dropping items, such as, but not limited to, ropes or climbing hardware; 4. Cuts and abrasions resulting from skin contact with the Challenge Courses; 5. Failure of rope, slings, harnesses, climbing hardware, anchor points, or any part of the Challenge Courses structures. I further acknowledge that the above list is not inclusive of all possible risks associated with the use of the Challenge Courses and that the above list in no way limits the extent or reach of this release and covenant not to sue. I accept full responsibility for my child s safety while in the Challenge Course area. I agree to instruct my child to abide by, and to help enforce, the following Challenge Course safety policies: 1. Roped climbers and belayers must wear helmets and harnesses appropriately. 2. Participants cannot have gum or candy in their mouth while participating. 3. Participants must have appropriate footwear. No open toed shoes. 4. Participants must follow all commands and instructions. 5. Participants must report immediately all accidents or equipment damage. 6. Shady Grove Ropes Course additional safety policies: a. LOW ROPES: All participants must be 5 years old. A spotter is required. b. HIGH ROPES: All participants must be 11 years old. To belay for high ropes you must be at least 16 years old. c. Climbers must be roped and belayed through a belay plate. Belays must be anchored. d. Lead climbers must use adequate protection to eliminate the possibility of a ground fall at all times. 7. Tuckahoe Rockwall additional safety policies: a. Climbers must be roped and belayed through a belay plate. Belays must be anchored. b. Lead climbers must use adequate protection to eliminate the possibility of a ground fall at all times. c. No unbelayed climbing above the bouldering line. 8. Camp Thunderbird Alpine Tower and Dual Zip Line additional safety policies: a. All participants MUST be at least 8 years old. b. All participants must have the physical and mental ability to climb a 50 ft tower. c. All participants with long hair must have hair tied up underneath the helmet. d. Participants on the ground must wear helmets while in the drop zone underneath the platform. The Y reserves the right to withdraw the participation of any child for failure to follow the Challenge Course Safety Policies, or for any conduct that is viewed as unsafe or inappropriate. In consideration of the use of the Challenge Courses, I acknowledge that I have read and agree on behalf of my child to abide by the Challenge Course Safety Policies. RELEASE, WAIVER of LIABILITY and INDEMNITY AGREEMENT In consideration for being permitted to utilize the facilities, services, and programs of the YMCA for any purpose, including but not limited to observation or use of facilities or equipment, or participation in any program affiliated with the YMCA, without respect to location, for himself or herself as well as on behalf of any individuals included on this program registration and any personal representatives, heirs, and next of kin (the Undersigned ), the Undersigned hereby acknowledges, agrees and represents that the Undersigned has, or will immediately upon entering or participating, inspect and carefully consider such premises and facilities or the affiliated program. It is further warranted that such entry into the YMCA for observation or use of any facilities or equipment or participation in such affiliated program constitutes an acknowledgment that such premises and all facilities and equipment thereon and such affiliated programs have been inspected and carefully considered and that the Undersigned finds and accepts same as being safe and reasonably suited for the purpose of such observation, use, or participation.

4 IN FURTHER CONSIDERATION OF BEING PERMITTED TO ENTER THE YMCA FOR ANY PURPOSE, INCLUDING BUT NOT LIMITED TO OBSERVATION OR USE OF FACILITIES OR EQUIPMENT, OR PARTICIPATION IN ANY PROGRAM AFFILIATED WITH THE YMCA, WITHOUT RESPECT TO LOCATION, THE UNDERSIGNED HEREBY AGREES TO THE FOLLOWING: 1. THE UNDERSIGNED HEREBY RELEASES, WAIVES, DISCHARGES AND COVENANTS NOT TO SUE the YMCA, its directors, officers, employees and agents (hereinafter referred to as "Releasees") from all liability to the Undersigned for any loss or damage, and any claim or demands therefore on account of injury to the person or property or resulting in death of the Undersigned, which is in any way associated with the Undersigned s presence in, upon, or about the premises or any facilities or equipment therein, or participation in any program affiliated with the YMCA, without respect to location. 2. The Undersigned hereby agrees to indemnify, save and hold harmless the Releasees and each of them from any loss, liability, damage, or cost they may incur which is in any way associated with the Undersigned s presence in, upon, or about the YMCA premises or in any way observing or using any facilities or equipment of the YMCA or participating in any program affiliated with the YMCA. 3. The Undersigned hereby assumes full responsibility for and risk of bodily injury, death, or property damage which is in any way associated with the Undersigned s presence in, about, or upon the premises of the YMCA and/or while using the premises or any facilities or equipment thereon or participating in any program affiliated with the YMCA. The Undersigned further expressly agrees that the foregoing RELEASE, WAIVER OF LIABILITY AND INDEMNITY AGREEMENT is intended to be as broad and exclusive as permitted by law of the state of Virginia and that if any portion thereof is held invalid, it is agreed that the balance shall, not withstanding, continue in full legal force and effect. THE UNDERSIGNED HAS READ AND VOLUNTARILY SIGNS THE RELEASE, WAIVER OF LIABILITY AND INDEMNITY AGREEMENT, and further agrees that no oral representations, statements, or inducement apart from the foregoing written agreement have been made. The UNDERSIGNED acknowledges that the YMCA of Greater Richmond is a charitable non-profit organization under the laws of the State of Virginia and nothing in this RELEASE, WAIVER OF LIABILITY AND INDEMNITY AGREEMENT shall be construed as a waiver of charitable non-profit status and/or benefits under Virginia law. (Revised 8/2016) I have read and understand the statements above regarding YMCA policies and procedures and, where authorization is required above, I give my consent (or have indicated otherwise).

5 CAMPER IN LEADERSHIP TRAINING (CILT) APPLICATION TEEN S INFORMATION: Child s Full Name (Last, First, Middle) Preferred Name City State Zip Home Phone Gender Male Female School Grade Age Date of Birth Best way to contact you (Please circle all that apply): Home Phone Cell Phone Tell us about yourself, feel free to elaborate on the back or with an attached piece of paper. Please return this application and the recommendation letter (completed by a non-family member) to your selected YMCA, no later than two weeks prior to the session you are applying for. Please list any past camp experience that you may have, most recent first. What are your expectations of the CILT Program? Do you have any Certifications or Awards (CPR, First Aid, etc.)? What are your two most defining characteristics and why?

6 CILT APPLICATION cont. CILT s name: Provide an example of a time where you had to demonstrate your ability to be a leader? Why should you be chosen to be a CILT for the Summer? Any other information that you think will be helpful for us to know about you during this application process? Lastly, you are required to turn in 2 reference letters as part of your application. These need to be attached to your application before you turn it in. I understand and have attached the appropriate number of required reference letters. (Initial)