YOUTH LMTI Summer Leadership Registration 2023

LMTI Summer Leadership Conference

The 2023 Summer Leadership Conference will take place Monday, August 21 - Friday, August 25 at YMCA Camp Ralph S. Mason.
I am a member of LMTI's Youth Advisory Council (YAC)*

yesno
Participant Name*

First NameLast Name
Preferred Name (We'll use this on all correspondence with you and your name tag)*
Participant Email*
example@example.com
Gender*
Pronouns I Use (i.e. she/her, he/him, they/them, etc.)*
Housing Preference: All students who attend the Summer Leadership Conference will be assigned to a dormitory style cabin chaperoned by our trained adult staff. It is our priority that all students have a comfortable and safe experience at LMTI. Please select the housing option that you feel best suits your needs, and feel free to contact us with any questions.*

FemaleMaleGender Inclusive
Date of Birth*

MonthDayYear
Date
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
What will your grade for the 2023-2024 school year be?*
What school do you attend?*
What is your Action Group (if applicable)?*
Please select a T-Shirt size.*

Emergency Contacts

In the event of an emergency, or in the event that the parent/guardian is unable to be reached, please provide two individuals that the LMTI Staff may contact to provide medical authorization or to transport the participant to/from Camp Mason.
Emergency Contact #1*

First NameLast Name
Phone Number*
555-555-5555
Relationship to the Participant*
Emergency Contact #2*

First NameLast Name
Phone Number*
555-555-5555
Relationship to the Participant*

Insurance Information
The participant is covered by medical insurance.*

Yes (please fill out the info below or attach a copy of your insurance card at the bottom of this page)No
Insurance Company Name
Phone Number
Policy Holder Name

First NameLast Name
Policy Holder Date of Birth

MonthDayYear
Policy Number
Group Number
Insurance Information (front/back of card)

Browse Files

Cancelof

Release, Waiver, & Indemnification

LMTI, a program of Partners in Prevention
A. Consent for Attendance and Participation
This information provided in this form is correct and my child has permission to participate in all activities at YMCA Camp Mason (23 Birch Ridge Road, Hardwick NJ 07825) on August 21 - 25, 2023

B. Insurance
I agree to pay any medical bills (independently or through insurance) that may arise as a result of injuries incurred at the LMTI Summer Leadership Conference.

C. Medical Consent
I hereby consent and authorize the LMTI Health Care Staff to administer medication as needed to the participant as indicated by me on this application. I understand that the LMTI Summer Leadership Conference occurs in an outdoor setting and hereby authorize trained LMTI Staff or Health Care Staff to administer first aid to the participant when necessary. In the event of a medical emergency, I understand that I will be contacted as soon as possible and that my child may be transported to Newton Memorial Hospital, or another hospital as may be necessary or otherwise determined. I give permission for the administration of all needed medicines, the performance of all surgical and other treatment, and the administration of any anesthetic or injection which, in the opinion of the attending physician, may be necessary and/or advisable in the event of any medical emergencies regarding my child. It is understood that reasonable efforts shall be made to reach me prior to rendering emergency treatment to the patient. Without limiting the permissions I granted regarding medical treatment and transportation in this paragraph and below, in the event that I am unavailable, I designate the aforementioned emergency contact to provide medical consent on my behalf, or to transport my child to/from Camp Mason or to/from the medical facility.

D. Transportation Consent
I give permission for LMTI staff or volunteers to transport my child away from YMCA Camp Mason/LMTI Summer Leadership Conference for any reason that is deemed necessary by LMTI staff. I understand that in the event that my child must return home (including psychological or physical medical needs, rule infringement, or any other occurrence deemed necessary by LMTI staff), I am responsible for providing transportation.

E. Photo/Video Release
I give permission for photographs/video footage to be taken of the participant (either in person or online), and for photographs/video footage in which the participant is included to be used for purposes of publicity by LMTI and NCADD-Hudson/Partners in Prevention. This includes publication of pictures/video on LMTI websites social media outlets.

F. Chaperone Consent
In the event that my child’s advisor leaves camp during the week, I understand that a trained LMTI adult volunteer or staff member will serve as their action group leader for the duration of the advisor's absence of the conference.

G. COVID-19
I understand that LMTI and YMCA Camp Mason are operating in accordance with Covid-19 federal, state, and local youth camp safety guidelines. I understand the dangerous and infectious nature of the COVID-19 virus, and acknowledge that the COVID-19 virus may be transmitted from person to person even if all federal, state, local, and other COVID-19 guidelines are followed. I understand that LMTI, YMCA Camp Mason, and NCADD-Hudson/Partners in Prevention cannot guarantee that any person will not become infected with the COVID-19 virus. I understand and authorize that the participant may be administered a rapid or other COVID-19 test during camp in the case of COVID-like symptoms or if an exposure occurs. I understand that LMTI staff will only reach out to me (the participants' caregivers) if there is a positive test result for that participant, and I will not be notified otherwise. I also understand that if the participant is tested and the test is positive, the participant will quarantine as per health guidelines, and that I (or my designee) am required to pick the participant up from YMCA Camp Mason by day's end. If the participant is unable to be picked up, I understand and authorize that an LMTI staff member or other designee may provide the participant with transportation from Camp Mason to the participant's home. NOTWITHSTANDING THESE RISKS, I ACKNOWLEDGE THAT THE PARTICIPANT IS VOLUNTARILY PARTICIPATING WITH KNOWLEDGE OF THE DANGERS INVOLVED. I HEREBY AGREE, FOR MYSELF AND THE PARTICIPANT, TO ACCEPT AND ASSUME ALL RISKS OF INJURY, ILLNESS, DISABILITY, DEATH, AND/OR PROPERTY DAMAGE ARISING FROM THE PARTICIPANT ATTENDING THE CONFERENCE, HOWEVER CAUSED. TO THAT END, IN ADDITION TO AND NOT IN LIMITATION OF THE RELEASE, WAIVER, AND INDEMNIFICATION SET OUT IN PARAGRAPH H, BELOW, I WILL NOT HOLD LMTI, YMCA CAMP MASON, NCADD-HUDSON/PARTNERS IN PREVENTION, OR ANY OF THEIR STAFF, PRINCIPALS, OR AGENTS, RESPONSIBLE FOR, AND HEREBY RELEASE EACH AND EVERYONE ONE OF THEM, FROM ANY CLAIMS, DAMAGES, LOSSES, INJURY, OR DEATH, ASSOCIATED WITH COVID-19 AND RELATED MATTERS.

If I have any questions regarding health/safety, I can contact Rachel Taylor, LMTI Director at rtaylor@pipnj.org.

H. Release, Waiver, and Indemnification
I, the undersigned parent/guardian, do hereby execute this release, waiver, and indemnification and agree to represent as follows: The release of YMCA Camp Ralph S. Mason, NCADD-Hudson/Partners in Prevention, the Lindsey Meyer Teen Institute and their employees, and agents from any and all liability, loss, damage, costs, claims or causes of action including, but not limited to, all bodily injuries and property damages arising out of the sole negligence or other acts or omissions of YMCA Camp Mason, NCADD-Hudson/Partners in Prevention, and the Lindsey Meyer Teen Institute I further agree to indemnify and hold harmless the said above from any and all liability, loss, damage costs, or causes of action, including attorney’s fees and witness costs, arising out of the undersigned participation in the Lindsey Meyer Teen Institute (LMTI) Summer Leadership Conference and other events scheduled for the 2023-2024 school year.
Parent/Guardian Name*

First NameLast Name
Relationship to Participant*
Parent/Guardian Phone Number*
555-555-5555
Parent/Guardian Email*
example@example.com
Parent/Guardian Signature*

Clear
Date*

MonthDayYear
Date

YMCA Camp Mason

Program Waiver- Youth
YMCA Camp Mason conducts its programs with the best interests of its participants in mind and has taken reasonable steps to provide appropriate equipment and well trained staff for these programs. However, these programs do have inherent risks and although safety procedures have been established to minimize these risks not all risks and hazards can be eliminated due to the nature of the activities offered.

Living in the natural environment can be unpredictable. Some of the possible risks include contact with wildlife, falling, cuts, burns, bruises, sprains, fractures, falling trees, falls during climbing, falling rocks during climbing, tipping over a canoe, falling into the water, drowning, near drowning, hypothermia, unpredictable weather conditions. All of these risks may result in injuries to the participant. I understand that Camp Mason’s intent is not to frighten me but wants me to be fully informed of all the risks. I understand that the risks listed above are not complete and that there are other risks that exist.

The potential of contracting Lyme Disease increases in rural settings such as Camp Mason. We encourage all participants to check themselves regularly for ticks and to be educated on the signs and symptoms of Lyme Disease, which may occur days or months after an encounter with a tick.

My signature below indicates that I fully understand the nature of the program at YMCA Camp Mason and I freely wish to participate. I know of no legal, physical or health reason why myself and/or my child cannot fully participate in the program that I am registering for. I agree to assume responsibility for the inherent risks identified herein and to those risks that are not specifically identified. I understand that it is my responsibility to participate in a safe manner, doing my best to follow the safety instructions provided to me
by the Camp Mason staff. I agree not to do anything that jeopardizes me or other members of my group. I (and my parents/guardians if a am a minor) assume and accept full responsibility for me and for injury, death and loss of personal property and expenses suffered by me as a result of those inherent risks and dangers identified herein, and those not specifically identified, as a result of my negligence or the negligence of others participating in the activity.

My signature authorizes the management and staff of YMCA Camp Mason to act for me according to their best judgment in the event of a medical emergency and/or routine medical care. By my signature I hereby waive, release and hold harmless the YMCA, its management, volunteers, agents, and staff from any and all liability for any injuries, death or illness sustained and/or incurred while at Camp and /or while using any facilities of, or participating in any of the activities of YMCA Camp Mason. I grant permission for emergency medical treatment and/or routine medical care by the YMCA camp staff, a rescue squad, private physician and/or hospital or emergency health care facility staff, under the same circumstances as above, if needed. Any such action will be taken in the best interest of my child and will be reported to me as soon as possible. My signature waives and/or releases YMCA Camp Mason from any and all liability and/or financial responsibility for any medical expenses incurred. I understand that YMCA Camp Mason does not carry or maintain health, medical or disability insurance coverage for any Participant. Each Participant is required to obtain their own medical or health insurance coverage.

In consideration of having myself or my minor child or ward participate in the Outdoor Center program to be offered by YMCA Camp Mason, I agree to waive and release all future claims, demands or causes of action which the undersigned and/or such participant might have by reason of any loss, damage, expenses, injury or death arising out of or in any way connected with such person’s participation in such program. I further agree to indemnify and hold harmless YMCA Camp Mason, their agents, officers, directors,
employees and volunteers from and against any such claim, demands or causes of action.

By signing below, I acknowledge that it is understood that YMCA Camp Mason is a non-profit corporation, organized exclusively for charitable and educational purposes, and as such, is immune from liability to its beneficiaries for the negligence of its agents, servants or employees under N.J.S.A. 2A:53A-7.

I give YMCA Camp Mason permission to use any photographs taken of myself and/or my child while participating in programs at Camp Mason.
Participant Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent/Guardian Name*

First NameLast Name
Parent/Guardian Phone Number*
555-555-5555
Parent/Guardian Email*
example@example.com
Parent/Guardian Signature*

Clear
Date*

MonthDayYear
Date
Should be Empty:

	Received	Date(s) Received
Diptheria, tetanus, pertussis (DTap) or (TdaP)
Tetanus booster (dT) or (TdaP)
Mumps, measles, rubella (MMR)
Polio (IPV)
Haemophilus influenza type B (HIB)
Pneumococcal (PCV)
Hepatitis B
Hepatitis A
Varicella (Chicken Pox)
Meningococcal miningitis (MCV4) B

	Name	Date Started	Reason	When is it given	Amount or dose given	How is it given (i.e. orally)
Medication 1
Medication 2
Medication 3
Medication 4
Medication 5
Medication 6
Medication 7
Medication 8
Medication 9
Medication 10

	Yes/No	If Yes, please explain
1. Ever been hospitalized?
2. Ever had surgery?
3. Have recurrent/chronic illnesses?
4. Had a recent infectious disease?
5. Had a recent injury?
6. Had asthma/wheezing/shortness of breath?
7. Have diabetes?
8. Had seizures?
9. Had headaches?
10. Wear glasses, contacts, or corrective eyewear?
11. Had fainting or dizziness?
12. Passed out/had chest pain during exercise?
13. Had mononucleosis (“mono”) in the past 12 months?
14. If menstruates, have problems with periods/menstruation?
15. Have problems with falling asleep/sleepwalking?
16. Ever had back/joint problems?
17. Have problems with diarrhea/constipation?
18. Ever had an eating disorder?
19. Have any skin problems?
20. Traveled outside the country in the past 9 months?
21. Have a peanut allergy?
22. Have depression or anxiety?
23. Ever been treated for emotional or behavioral difficulties?

LMTI Summer Leadership Conference

Health Information

Emergency Contacts

Insurance Information

Release, Waiver, & Indemnification

YMCA Camp Mason