2022 Summer Camp Health Form

Family/ Guardian Information
Family/Guardian 1 Name*

First NameLast Name
Family/Guardian 1 Email*
example@example.com
Family/Guardian 1 Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Family/Guardian 1 Relation to Youth*
Family/Guardian 1 Cell/Main Phone Number*
Please enter a valid phone number.
Family/Guardian 1 Work/Other Phone Number*
Please enter a valid phone number.
Family/Guardian 1 Employer*
Family/Guardian 2 Name

First NameLast Name
Family/Guardian 2 Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Family/Guardian 2 Email
example@example.com
Family/Guardian 2 Relation to Youth
Family/Guardian 2 Cell/Main Phone Number
Please enter a valid phone number.
Family/Guardian 2 Work/Other Phone Number
Please enter a valid phone number.
Family/Guardian 2 Employee
Is Family/Guardian 2 authorized to pick up your youth?

YesNo
Is Family/Guardian 2 authorized to change account information?

YesNo

Required Emergency Contacts and Authorized Pick Ups

In this section, please give us information on any other adults that are authorized to pick up your youth and/or be contacted in the case of an emergency
Required Emergency Pick Up 1 Name*

First NameLast Name
Required Emergency Pick Up 1 Phone Number *
Please enter a valid phone number.
Required Emergency Pick Up 1 Relation to Youth*
Authorized Pick Up 2 Name

First NameLast Name
Authorized Pick Up 2 Phone Number
Please enter a valid phone number.
Authorized Pick Up 2 Relation to Youth
Is Authorized Pick Up 2 to be contacted in the case of an emergency?

YesNo
Authorized Pick Up 3 Name

First NameLast Name
Authorized Pick Up 3 Phone Number
Please enter a valid phone number.
Authorized Pick Up 3 Relation to Youth
Is Authorized Pick Up 3 to be contacted in the case of an emergency?

YesNo

Program Permissions and Acknowledgement
This link will take you to the current licenses for our programs.

By signing below, I acknowledge that I have reviewed the copy of the current license certificate for this facility.
*

Clear
The Eugene Family YMCA has zero tolerance for abuse, mistreatment, or sexual activity among consumers within the organization. The Eugene Family YMCA is committed to providing all consumers with a safe environment and will not tolerate the mistreatment or abuse of one consumer by another consumer. Conduct by consumers that rises to the level of abuse, mistreatment, or sexual activity will result in intervention or disciplinary action, up to and including, dismissal from the program. *

Clear
The Eugene Family YMCA has zero-tolerance for unsafe behavior: bullying, threatening, intentionally hurting others, inappropriate touching, refusal to follow directions, purposefully damaging equipment or property, incidents that threaten the safety and livelihood of program participants and staff, theft, ANY discrimination/ harassment based on race, sexuality, gender identity, national origin, skin color, ability, age, religion, socioeconomic status, cultural backgrounds, lifestyles, symbols or gestures of hate. Eugene Family YMCA can 1)make accommodations for youth with disabilities on a case-by-case basis that do not fundamentally change the nature or the program or cause undue hardship on the organization 2) youths' age will be a factor in determining the best actions on a case-by-case basis.*

Clear
The Eugene Family YMCA has zero tolerance for abuse and will not tolerate the mistreatment or abuse in its programs. Any mistreatment or abuse by an employee or volunteer will result in disciplinary action, up to and including termination of employment or volunteer service and cooperation with law enforcement.*

Clear
My youth may be taken on field trips or excursions by bus or private motor vehicle, as well as on neighborhood walking excursions under required supervision.*

Clear
My youth may participate in swimming or other water activities under required supervision (OCC requires approved lifeguard).*

Clear
I recognize that participants are expected to follow all safety instructions and policies outlined in the family handbooks, remain in areas designated by staff and refrain from behavior harmful to oneself or others. I understand that failure to adhere to program and behavior policies could be cause for participant's dismissal.*

Clear
My youth has permission to participate in activities/swimming /transportation organized by YMCA staff. Activities may be led by non YMCA staff but YMCA staff are always present. *

Clear
I understand the YMCA is not responsible for personal property lost, damaged or stolen while participating in a YMCA program.*

Clear
I give permission for my youth to have sunscreen applied.*

Clear
I give permission for sunscreen to be applied to my youth.

YesNo
My youth may be photographed for publicity, news purposes and for the YMCA. This applies on site and off site.*

YesNo
Signature

Clear
I agree to defend, indemnify, and hold harmless the YMCA, its employees, directors, agents, insurers, and servants against any and all losses, damages, liabilities, claims, settlements, penalties, fines, interest, costs, or expenses of any kind, including attorney fees and fees and costs of enforcing any right under this indemnification section, arising out of or resulting from any claim of a third party.*

Clear
I understand that Eugene Family YMCA staff will try to reach me in an emergency and will give care whether I am reachable or not. I hereby authorize YMCA staff to act according to their best judgement in any situation requiring medical attention for the youth named in this release when I am not present. In an emergency, the Y has my permission to call an ambulance, or take my youth to any available physician or hospital at my expense to obtain medical treatment. In most emergencies, 911 is called and the youth is transported to the nearest hospital and treated by the on‐call physician. The family of the youth is notified as soon as possible.*

Clear
I understand that it is my responsibility to provide medical insurance coverage for the youth named in this release while they are participating in YMCA events and to provide accurate and complete medical information. *

Clear
I agree that the use of YMCA services and participation in activities or events shall be undertaken by me or my youth at our sole risk. I am aware and I approve of my youth having an opportunity to participate in program activities which may involve a degree of risk and I release, on behalf of myself and my youth, the YMCA, its employees, directors, agents, insurers, and servants from any and all claims arising out of or resulting from any injury, death, loss, or damage suffered by me or my youth, including such injuries arising from my youth’s participation in the YMCA’s activities and programs, including all required transportation, regardless of whether such injuries result, in whole or in part, from the negligence of the YMCA. *

Clear
I will follow all Covid-19 safety guidelines that the YMCA was instituted. I understand that the Y is following Early Learning Division and Oregon Health Authority. We are all doing our best to keep youth and staff safe.*

Clear
By signing this form I agree that all of the above statements are true and accurate.*

Clear
Today's Date*

MonthDayYear
Date
Any other questions/comments/concerns?
Should be Empty:

2022-23 School Year Health Form

Family/ Guardian Information

Required Emergency Contacts and Authorized Pick Ups

Youth Information

Program Permissions and Acknowledgement