ADULT LMTI Summer Leadership Application 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. (advisors and general volunteers that wish to attend staff development training on Sunday, August 20 should email RTaylor@pipnj.org and let them know by August 5. Please note Sunday is mandatory for YACs, CATS, and YAC/CATS Coordinators)
I am a(n):

AdvisorCATS MemberVolunteer
Name*

First NameLast Name
Preferred Name (We'll use this on all correspondence with you and your name tag)*
Email*
example@example.com
Gender*
Pronouns I Use (i.e. she/her, he/him, they/their, 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
Home Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Cell Phone Number*
555-555-5555
Work or Alternate Phone Number
555-555-5555
Please select a T-Shirt size.*
What is your Action Group (if applicable)?

Health Information

Please answer the following health related questions. This information is viewed only by our health care staff.
Are you allergic to any food or medication?*

YesNo
If yes, name the item(s), indicate the reaction(s), and management.
(For example: Peanuts - Hives - Benadryl)
Do you use an EPI-Pen? (If yes, you MUST bring it with you!)*

YesNo
Do you have asthma?*

YesNo
If yes, name the trigger(s) below.
(For example: Dust, Pollen, Dogs, Exercise, etc.)
Do you use an inhaler? (If yes, you MUST bring it with you!)*

YesNo
Do you have any limitations on activities, or require any accommodations that we should be aware of?
(For example: Dust, Pollen, Dogs, Exercise, etc.)
Please check the appropriate box(es) regarding food restrictions.*

Medication Information- Please list all medications (including over the counter or nonprescription drugs) taken routinely. All medication MUST be kept in the original packaging/bottle that identifies the prescribing physician, the name of the medication, the dosage, and the frequency of administration. All medications MUST be handed into our medical staff upon arrival. If no meds are taken, please skip this section.

	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

Medical History- Please answer the following: Have you...*

	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/had 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?

Is there anything we should know about your mental mental health (include any specific diagnoses, difficulties, and/or major life events)?*
Is there anything else you'd like to tell us that we've forgotten to ask?*

Emergency Contacts

In the event of an emergency please provide two individuals that the LMTI Staff may contact on your behalf.
Emergency Contact #1*

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

First NameLast Name
Phone Number*
555-555-5555
Relationship to You*

Release, Waiver, & Indemnification

LMTI, a program of Partners in Prevention
A. Attendance and Participation
This information provided in this form is correct and I will attend the LMTI Summer Leadership Conference at YMCA Camp Mason (23 Birch Ridge Road, Hardwick NJ 07825) from August 20 - 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 me. 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 me when necessary. In the event of a medical emergency, I understand that I 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, 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.

D. Photo/Video Release
I give permission for photographs/video footage to be taken of the me, and for photographs/video footage in which I am in 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.

E. Consent for Text Message Alerts & App Communication
I give permission for LMTI to send event and info alerts via text message or identified cell phone app via the cell phone number provided. I can opt out of this communication by contacting the LMTI Staff at any time.

F. 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 I 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 if I am tested and the test is positive, I will quarantine as per health guidelines, and that I am required to leave YMCA Camp Mason by day's end. NOTWITHSTANDING THESE RISKS, I ACKNOWLEDGE THAT I AM VOLUNTARILY PARTICIPATING WITH KNOWLEDGE OF THE DANGERS INVOLVED. I HEREBY AGREE TO ACCEPT AND ASSUME ALL RISKS OF INJURY, ILLNESS, DISABILITY, DEATH, AND/OR PROPERTY DAMAGE ARISING FROM 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 G, 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.

G. Release, Waiver, and Indemnification
I, the undersigned, 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.
Signature*

Clear
Date*

MonthDayYear
Date
YMCA Camp Mason

Program Waiver- Adult
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.
Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
555-555-5555
Email*
example@example.com
Signature*

Clear
Date*

MonthDayYear
Date
Should be Empty:

LMTI Summer Leadership Conference

Health Information

Emergency Contacts

Release, Waiver, & Indemnification

YMCA Camp Mason