Registration Form

AUTHORIZATION FOR EMERGENCY MEDICAL TREATMENT:

As the parent or legal guardian of the above named student at School, I hereby consent to the immediate transfer of the above student to any licensed hospital or urgent care center in the event of a medical emergency. I further consent to the administration of any emergency medical treatment deemed necessary by a licensed physician or first responder. I understand that all reasonable attempts will be made to contact me in advance of any treatment if the circumstances permit. I authorize School to release information to facilitate the medical or surgical care of my child, or as is necessary to complete a claim for health insurance.

CONSENT TO MEDICAL TREATMENT FOR STUDENT BY THE MEDICAL DEPT.

I hereby authorize the Health Center to administer medical care and treatment to the above named student, including over-the-counter medication. I further authorize School and any licensed physician retained by School to release medical records and/or information pertaining to the diagnosis or treatment of the above-named student when such disclosure is necessary for the purpose of evaluation, treament and any other supportive service to be provided to the above-named student or is necessary to complete a claim for health insurance.

I am 18 years of age or older and, if not, my Mother/Father/Legal Guardian has also signed below. For my participation in activities to be conducted by the National Council of Young Men’s Christian Associations of the United States of America (YMCA of the USA) , I hereby give my permission and consent, now and for all time, to YMCA of the USA and collaborating third parties to make, reproduce,
edit, broadcast or rebroadcast any video film, footage, sound track recordings and photo reproductions of me and/or my narrative account of my experience within said activities, for publication, display, sale or exhibition thereof in promotions, advertising, education and legitimate business uses without any compensation to, and/or claim, by me. I may, or may not be, identified in such reproductions; however, I shall not be stated by name to have endorsed any particular commercial products or commercial services.

I further agree to the following:

• Any video film, footage, sound track recordings, and photo reproductions of me and/or my narrative account of my experience during said activities, I authorize, according to this Release, shall belong to YMCA of the USA and collaborating third parties. Therefore, they will have full right of disposition of
  any video film, footage, sound track recordings and photo reproductions of me and/or my narrative account of my experience within said activities;
• Any video film, footage, sound track recordings and photo reproductions of me and/or my narrative account of my experience within said activities will not be subject to any obligation of confidentiality and may be shared with and used by YMCA of the USA and collaborating third parties;
• YMCA of the USA and collaborating third parties collaborating shall not be liable for any use or disclosure to a third party of any video film, footage, sound track recordings and photo reproductions of me and/or my narrative account of my experience; and
• YMCA of the USA and collaborating third parties shall exclusively own all known or later existing rights to worldwide and shall be entitled to the unrestricted use any video film, footage, sound track recordings and photo reproductions of me and/or my narrative account of my experience for any
  purpose without compensation to me.

I agree that my consent and this release are irrevocable. I hereby release and discharge YMCA of the USA and collaborating third parties from any and all claims in connection with the uses and reproductions, any video film, footage, sound track recordings and photo reproductions of me and/or my narrative account of my experience as described herein.