2018-2019 School Year School: Child s Last Name: First Name: Sex: M F Birth date: / / Age: Home Phone: ( ) Home Address: Cell Phone: ( ) City: State: Zip: Child lives with: Mom Dad Both Parents Other Begin Expanded Learning Program: / / Grade: Room Number: Teacher s Name: 1 st Parent/Guardian Name: Relationship: _ Home Address: Home Phone:( ) City: State: Zip: Email Address: Employer s Name: Work Phone: ( ) Employer s Address: _ City: State: Zip:
2 nd Parent/Guardian Name: Relationship: Home Address: Home Phone:( ) City: State: Zip: Email Address: Employer s Name: Work Phone: ( ) _ Employer s Address: _ City: State: Zip: Emergency Information In Case of Emergency Family Doctor Name: Doctor s Phone:( ) Doctor s Office Address: City: Medical Insurance Company: Policy Number: Emergency Contacts (Other Than Parents): Phone: ( ) Name: Relationship: Phone: ( ) Name: Relationship: Phone: ( ) Name: Relationship: People Authorized to Pick-up your child: Name: Relationship: Phone: ( )
Is there anyone you DO NOT want to pick-up your child? Authorization / Waiver: 1. I give permission for my child to participate in activities, field trips, over-nights, and I give permission for the WRAP/YMCA program to use any picture for any promotional purpose. 2. In the event that I cannot be reached in an emergency, I hereby give permission for the Physician selected by the Director to hospitalize, secure proper treatment for and to order injections anesthesia, surgery for my child as name above. 3. I understand that I am responsible for the medical care fees if my child should be injured at the WRAP/YMCA program, or during any WRAP/YMCA activity and/or field trip. 4. I have read and understand the above and have completed the information to the best of my ability. 5. I have read and received the Expanded Learning Program Parent Handbook. I agree to follow the policies and procedures of the. Signature Consent to Media Child s Name: _ Parent s Name: I hereby give the YMCA of Greater Long Beach, it s successors and assigns, the absolute and irrevocable right and permission with respect to the photographs, videos, motion pictures and/or sound recordings being taken of my child: (a) to use, re-use, publish and re-publish the same, in whole or in part, severally or in conjunction with other photographs or recordings, in any medium and for any purpose whatsoever, and (b) to use my child s name therewith. I hereby release and discharge the YMCA of Greater Long Beach from any claims and demands arising out of or in connection with the use of such photographs, videos and motion pictures and the negatives thereof, and the recordings, shall constitute your sole property, this full right of disposition whatsoever. Please check below: FACEBOOK PICTURE CONSENT Yes, I consent for my child s photo(s) to appear on the YMCA of Greater Long Beach Facebook page.
No, I do not consent for my child s photo(s) to appear on YMCA of Greater Long Beach Facebook page. Parent s Printed Name Parent s Signature Parent Handbook I have received and read a copy of the Parent Handbook. I understand the policies of the WRAP/YMCA Expanded Learning Program, and I agree to abide by them. Signature I,, the parent/guardian of, DO authorize my child to sign themselves out at the end of the WRAP/YMCA program daily at 6:40PM (or earlier with an approved, signed Early Release Form). I understand that the EPIC: will not be responsible for the welfare of my child once they have been singed out. (This section gives permission for your child to walk home or be picked up outside of Stephens Middle School.) Parent/Guardian Signature ---------------------OR---------------------- I,, parent/guardian of, DO NOT authorize my child to sign themselves out at the end of the EPIC:. I understand that an authorized person or myself are responsible for signing my child out daily at 6:40 (or earlier with an approved, signed Early Release Form). Medical History Form Name: Grade: Birth date: Parents/Guardian: Home Phone:( ) Home Address: Number/Street City State Zip Parent/Guardian 1: Place of Employment: Phone:( )
Parent/Guardian 2: Place of h h h h h h h h h HEALTH HISTORY (Check giving approximate dates) Measles Polio Surgery (Major) Employment: German Measles Diabetes Accidents (Major) Chicken Pox Heart Disease Head Injury Mumps Kidney Disease Tuberculosis Whooping Cough Rheumatic Fever Other Exposure to contagious disease in the past two weeks of last Physical Check-up Dental Check-up CHILD SUBJECT TO: Colds Bronchitis Fainting Bed Wetting Other Sore Throats Asthma Convulsions Sleep Walking Ear Infections Allergies Headaches Stomach Aches ALLERGIES: IMMUNIZATIONS (give approximate dates) Penicillin Tetanus HIB Bee Stings Diphtheria _ Hepatitis B Foods Whooping Cough Mumps Other Medications Measles Other Other Allergies Rubella Other comments pertinent to child s health Any special needs or conditions We (I) the undersigned understand that at the YMCA of Greater Long Beach and its expanded learning programs and day camps, strenuous physical activity are a regular part of child care. To the best of my knowledge, our child is in excellent physical health, and/or needs no restrictions from strenuous physical activity. If we have any questions regarding our child s health we understand that is our obligation to seek professional medical advice and inform the WRAP/YMCA program of any restrictions on our child s activities. Signature
Authorization and Consent for Treatment I/We the undersigned, parents of: _ A minor, do hereby authorize the YMCA of Greater Long Beach, it s agents, branches, employees, and volunteers as agents for the undersigned to consent to any X- ray examination, anesthetic, dental, medical or surgical diagnosis, treatment and hospital care which is deemed advisable and is to be rendered under the general or specific supervision of any physician, dentist and surgeon licensed hospital whether such diagnosis or treatment is rendered at the office of said physician or hospital. It is understood that this authorization is given in advance of any specific consent to any and all such diagnosis, treatment of hospital care which the aforementioned physician in the exercise of his best judgment may deem advisable. This authorization is given pursuant to the provision of section No. 69.10 of the Civil Code of California. I understand that I am responsible for the medical fees of my child, if he/she should be injured or is ill at the YMCA of Greater Long Beach, or during YMCA of Greater Long Beach activities or field trips. My Insurance Carrier is: My Policy Number is: Please send a copy of your insurance form to insure speedy care for your child. I/We will not hold the YMCA of Greater Long Beach responsible for any injury that should occur to my child during regular activities at the WRAP/YMCA program. Parent s Printed Name Parent s Signature
YMCA OF GREATER LONG BEACH RELEASE AND WAIVER OF LIABILITY AND INDEMNITY AGREEMENT IN CONSIDERATION of being permitted to utilize the facilities, services and programs of the YMCA (or for my children to so participate) for any purpose, including, but not limited to observation or use of facilities or equipment, or participation in any off-site program affiliated with the YMCA, the undersigned, for himself or herself and such participating children and any personal representatives, heirs, and next of kin, hereby acknowledges, agrees and represents that he or she has, or immediately upon entering or participating will, 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 acknowledgement that such premises and all facilities and equipment thereon and such affiliated program 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 by the undersigned and such children. 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 OFF-SITE PROGRAM AFFILIATED WITH THE YMCA, THE UNDERSIGNED HEREBY AGREES TO THE FOLLOWING: 1. THE UNDERSIGNED, ON HIS OR HER BEHALF AND BEHALF OF SUCH CHILDREN, HERBY RELEASES, WAIVES, DISCHARGES AND COVENANTS NOT TO SUE the YMCA, and/or branch affiliates, its directors, officers, employees, and agents (hereinafter referred to as "releases") from all liability to the undersigned or such children and all his personal representatives, assigns, heirs, and next of kin 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 or such children whether caused by the negligence of the releases or otherwise while the undersigned or such children is in, upon, or about the premises or any facilities or equipment therein or participating in any program affiliated with the YMCA. 2. THE UNDERSIGNED HEREBY AGREES TO INDEMNIFY AND SAVE AND HOLD HARMLESS the releasees and each of them from any loss, liability, damage or cost they may incur due to the presence of the undersigned of such children 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 whether caused by negligence of the releasees or otherwise. 3. THE UNDERSIGNED HERBY ASSUMES FULL RESPONSIBILITY FOR AND RISK OF BODILY INJURY, DEATH OR PROPERTY DAMAGE to the undersigned or such children due to negligence of releasee or otherwise while 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 AND INDEMNITY AGREEMENT is intended to be as broad and inclusive as is permitted by the law of the State of California and that if any portion thereof is held invalid, it is agreed that the balance shall, notwithstanding, continue in full legal force and effect.
THE UNDERSIGNED HAS READ AND VOLUNTARILY SIGNS THE RELEASE AND WAIVER OF LIABILITY AND INDEMNITY AGREEMENT, and further agrees that no oral representations, statements of inducement apart from the foregoing written agreement have been made. I HAVE READ AND UNDERSTAND THIS RELEASE. Print Name Print Name Signature of Applicant/Parent Signature of Second Applicant/Parent Name of Child in Program Student s Name: Student Information 2018-2019 School Year Grade: Student s Birth date: Food Allergies: Medications: Medical Conditions: Home Address: Parents/Guardian Cell Phone: Home Phone: Work Phone: Child lives with (Circle One): Both Parents Mother Father Grandparent Other: Parents/Guardian s Name: Parents/Guardian s Name:
Only the following people pick up my child: below are authorized to Name Relationship Phone Number Please list individuals that may NOT pick-up your child: