WTRC PARTICIPANT MEDICAL FORM 2017

Is this your first submission? *

YES NO

If NO, please provide approximate date of previous submission:

- Month - Day Year

Participant Information

Participant's Name *

First Name Last Name

Birth Date *

Month Day Year

Age *

On first day of program

Gender *

Male Female

Address *

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

T-Shirt Size - Not Offered for All Programs *

Youth Small Youth Medium Youth Large Adult Small Adult Medium Adult Large Adult XL

Parent/Guardian Information #1

Name *

First Name Last Name

Home Number *

- Area Code Phone Number

Cell Number

- Area Code Phone Number

E-mail *

Parent/Guardian Information #2

Name

First Name Last Name

Home Number

- Area Code Phone Number

Cell Number

- Area Code Phone Number

E-mail

Alternate Emergency Contact Information

Emergency Contact's Name *

First Name Last Name

Relationship *

Phone Number *

- Area Code Phone Number

Alt. Phone Number

- Area Code Phone Number

Physician Contact Information

Physician's Name

First Name Last Name

Phone Number

- Area Code Phone Number

Dentist/Orthodontist Name

First Name Last Name

Phone Number

- Area Code Phone Number

ALLERGIES

Allergies *

No Allergies Bee/Wasp Stings Hay Fever Food Allergy (Describe Below) Medicine Allergy (Describe Below)

Please Describe *

ANAPHYLAXIS CARE

Anaphylaxis Care *

Not Applicable My child uses an Epi-Pen/Similar. I authorize camp staff to facilitate use. EMS will always be called. I must complete the Administering Medication section later on this form. Other (Please Describe Below) If applicable, I must complete the Administering Medication section later on this form.

Allergen(s): *

Other Information

INHALERS

Inhaler Use *

Not Applicable My child uses an inhaler. I authorize camp staff to faciilitate use. I must complete the AUTHORIZATION FOR ADMINISTERING MEDICATIONS section later on this form. Other (Please Describe Below) If applicable, I must complete the AUTHORIZATION FOR ADMINISTERING MEDICATIONS section later on this form.

Diagnosis/Condition: *

Symptoms of Condition: *

Other Information We Should Know:

IMMUNIZATIONS

Immunizations *

YES, my child's immunizations DO comply with the Ohio Dept. of Health requirements. NO, my child's immunizations DO NOT comply with the Ohio Dept. of Health requirements. Please explain below.

If YES above, please check all immunizations your child has received below:

HBV - Hepatitis B Vaccine DTap - Diptheria, Pertussis, Tetanus Vaccine TdaP - Tetanus Booster MMR - Mumps, Measles, Rubella Vaccine OPV - Oral Polio Vaccine VPD - Varicella Vaccine

If you marked NO above or an immunization has not been received, please check the statement below and describe.

I have read and understand that in the event of an outbreak of any disease checked above, my child will be subject to exclusion from this program for the duration of the outbreak, which would be until at least two weeks after the last reported case occurs, unless I provide a statement signed by the physician who saw and diagnosed my child as having had the disease in question. (A physician diagnosed history of disease is accepted for measles and mumps only. A positive laboratory test is the only acceptable proof of having had rubella.) Should a child be asked to leave this program due to an outbreak of any disease, they would not be eligible for any portion of their participation fees.

Please Describe

DIET/NUTRITION

Providing a quality experience for our participants begins with making sure our staff is made aware in advance of any unique special needs or accommodations your child may require.

Diet/Nutrition *

No Restrictions Vegetarian Lactose Intolerant Gluten Free Other (Please Describe)

Please Describe

ACTIVITY RESTRICTIONS

Providing a quality experience for our participants begins with making sure our staff is made aware in advance of any unique special needs or accommodations your child may require.

Activity Restrictions *

My child can participate WITHOUT restrictions. My child can participate WITH restrictions. (Please Describe)

Please Describe

MENTAL, EMOTIONAL AND SOCIAL HEALTH

Providing a quality experience for our participants begins with making sure our staff is made aware of any unique mental, emotional or social challenges.

Social Health

My child has been or currently is being treated for ADD or AD/HD My child has been or currently is being treated for emotional or behavioral difficulties My child has had a significant life event in the past year, i.e. death or illness

If you checked one or more boxes above, please describe:

Please review the following permissions/authorizations and check as applicable.

ALTERNATE SIGN-IN/OUT AUTHORIZATION: Washington Township Recreation Department policy requires that all participants be signed out by a parent or named guardian. However, camp participants who are 13 yrs or older may be signed into this program or released into their own care afterwards. We require authorization from the parents in this case. Please refer to our CAMP parent resource guide for additional information.

Sign-In/Out Authorization *

YES, I give my 13+ year old child permission to sign-in/out on their own. I understand and agree that if this authorization is given, my child will be on his/her own prior to 9:00am and after 4:00pm for camp programs and will not be permitted to participate in Extended Care activities before or after camp hours. The listed child will sign themselves in and out of camp and will not be supervised prior to 9:00am and after 4:00pm. I provide this authorization voluntary and hereby release the Washington Township Recreation Department of all liability prior to or following signing in or out of camp activities. NO, I do not give my 13+ year old child permission to sign-in/out on their own My Child is 12 & Under - Does Not Apply

PERMISSION TO TRANSPORT AUTHORIZATION: For field trips and/or medical emergencies Washington Township Recreation Department staff may transport your child in a department vehicle. Please refer to our CAMP or REC'ING CREW parent resource guides for additional information.

Permission to Transport Authorization *

YES, I give WTRC permission to transport my child for field trips and/or medical care. NO, I do not give WTRC permission to transport my child.

PERMISSION TO SWIM AUTHORIZATION: Safety in our pools and aquatic settings is important. Unless indicated below, all children will be permitted in our 2' recreational pool. Those children desiring access to our main pool and water slide will be tested for swimming ability to determine which pool areas they may enter. Please refer to our CAMP or REC'ING CREW parent resource guides for additional information.

Permission to Swim *

YES, I give permission for my child to participate in swimming/water activities in water depth of 2 feet or more. My child will be tested by pool staff to determine safe boundaries. NO, I DO NOT give permission for my child to participate in swimming/water activities in water depth of 2 feet or more. My child will be limited to the recreation pool and supervised canoe activities. NO, I DO NOT give permission for my child to participate in ANY swimming/water activities.

AUTHORIZATION FOR ADMINISTERING MEDICATIONS: Although we discourage the use of medication during program hours, should it become necessary for WTRC staff to facilitate day-time medications we must have the parents' authorization to do so. Parents must attach a MEDICATION AUTHORIZATION form.

(THIS INCLUDES ANY CAMPER REQUIRING INHALER/MEDICATION FOR ANAPHYLAXIS)

Please refer to our CAMP or REC'ING CREW parent resource guides for additional information.

Medication *

NO, I do NOT authorize WTRC staff to administer medication to my child during program hours YES, my child needs medication. I authorize WTRC staff to administer medication to my child during program hours as directed. A MEDICATION AUTHORIZATION form and Signed Physician's Statement must be on file. YES, in the event that my child needs medication, I authorize WTRC staff to administer medication to my child during program hours as directed. At that time, I understand that a MEDICATION AUTHORIZATION form and Signed Physician's Statement must be on file.

Click here to fill out our MEDICATION AUTHORIZATION FORM now or get the link on our website at a later time.

The following upload button is for our staff only. It will be used for our staff to link Medication Authorization forms.

STAFF ONLY: Attached Medication Authorization form(s) here.

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Authorization(s) for Administering Medication

ALTERNATE PICK-UP AUTHORIZATION: Use this section to designate drivers other than yourself who you authorize to pick-up your child from this program. A reminder that designated alternates MUST present a driver's license to pick up the participant. Please refer to our CAMP or REC'ING CREW parent resource guides for additional information.

Authorized Name

The following upload button is for our staff only. It will be used to add additional authorized drivers to this list using emails, voice-mails or other documentation.

STAFF ONLY: Upload Additional Documentation Here for Designated Alternates

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Staff Only Section

READ CAREFULLY

The undersigned parent/guardian desires to allow his or her child (“Participant”) to participate in a camp/afterschool program at Washington Township (“Program”). Participant and parent/guardian understand and acknowledge that participation in this Program is voluntary. In exchange for being permitted to participate in Program, Participant and parent/guardian agree to this full Waiver and Release.

Participant and parent/guardian understand and acknowledge that there are risks inherent in participating in this Program, including possible personal injury, injury to property, or death. Participants and parent/guardian agree to make themselves aware the risks and hazards associated with this Program. Parent/guardian expressly acknowledge and agree that it is the responsibility of parent/guardian to inform Participant of any potential risks involved in Program activities. Participant and parent/guardian acknowledge that the activities involved in Program may include (but are not limited to) various types of physical exertion, running, and other conduct involved in physical activity. As a result, thsi Program may result in serious injuries, including injury to the head or brain, injury to all internal organs, injury to all bones, joints, muscles, ligaments, tendons, and other aspects of the muscular-skeletal system, any other injury to any part of the body, or death. In addition, this Program will involve field trips to various locations, each involving unique risks to this Participant, including risk of injury during transportation to the field trip. Participant and parent/guardian acknowledge and understand that there is a possibility of unforeseen and unpredictable events and risks inherent in this Program that can result in serious bodily injury or death when participating in this Program. Participants and parent/guardian further understand that there may be other risks in addition to those listed above that may pose a danger to Participants and other individuals, and Participant and parent/guardian expressly assume all risks, known and unknown, including risks posed by field trips. For purposes of this Waiver and Release, “Program” includes all field trips and any other Program-related activities.

With the above in mind, and being fully aware of the risks (known and unknown) and possibility of injury and loss involved, the undersigned Participant and parent/guardian consent to have Participant participate in this Program. Parent/guardian, on behalf of himself/herself, any other parent/guardian, Participant, executors or other representatives, waive and release all rights and claims for damages that the parent/guardian or Participant may have against Washington Township and its representatives, agents, members of the board of trustees, employees, representatives, and volunteers (collectively, “Washington Township”). By signing this Waiver and Release, Participant and parent/guardian agree to waive, release and hold harmless Washington Township and its agents, members of the board of trustees, employees, representatives and volunteers from any and all present and future claims, lawsuits, actions, liabilities, demands, damages, costs, expenses, loss of services, actions and causes of action whatsoever for, upon, or by reason of, any present or future loss, injury, disability or damage of any kind whatsoever (whether to person, including death, or to property, and whether negligent or otherwise), known or unknown, anticipated or unanticipated, at any time arising out of or relating in any way to the activities involved in this Program or for any treatment of injury sustained during this Program. This Waiver and Release expressly includes any claims arising from or relating to the administration of medication by Washington Township. Participant and parent/guardian further agree to indemnify, defend, and hold Washington Township free and harmless from and against all present and future claims, lawsuits, damages, costs, expenses, loss of services, actions and causes of action, including actions for loss of life, whether known or unknown, anticipated or unanticipated, arising out of or relating in any way to this Program or related activity.

The undersigned parent/guardian also affirms that Participant now has and will continue to maintain proper hospitalization, health, and accident insurance coverage which the undersigned acknowledges as adequate for both Participant’s protection and the parent/guardian’s own protection. Participant is covered by primary health/medical/accident insurance (please list provider below). Participant and parent/guardian represent and warrant that Participant is qualified, in good health, and in proper physical condition to participate in this Program and all activities associated with this Program.

Agreement to this Waiver and Release is voluntary and in exchange for permission of Particiapnt to participate in this program. Participant and parent/guardian acknowledge that they have been provided sufficient time to read and consider the nature and scope of this Waiver and Release. It is the intent of the undersigned that this Waiver and Release be complete and unconditional and be applied to the fullest extent permitted by law. If any part or portion of this Waiver or Release is held invalid, the remainder shall continue in full force and effect.

Participant is covered by primary health/medical/accident insurance through: *

Please Check *

I have carefully read and understand the foregoing Waiver and Release, and agree to the terms and conditions of this Waiver and Release. By checking this box and typing my name below, I am electronically signing this Waiver and Release.

Parent/Guardian Name *

Medical Release and Authorization

As Parent and/or Guardian of the named participant, I hereby authorize the diagnosis and treatment by a qualified and licensed medical professional, of the minor child, in the event of a medical emergency, which in the opinion of the attending medical professional, requires immediate attention to prevent further endangerment of the minor’s life, physical disfigurement, physical impairment, or other undue pain, suffering or discomfort, if delayed.

Permission is hereby granted to the attending physician to proceed with any medical or minor surgical treatment, x-ray examination and immunizations for the named participant. In the event of an emergency arising out of serious illness, the need for major surgery, or significant accidental injury, I understand that every attempt will be made by the attending physician to contact me in the most expeditious way possible. This authorization is granted only after a reasonable effort has been made to reach me.

Permission is also granted to the Washington Township and its staff to provide the needed emergency treatment prior to the child’s admission to the medical facility.

Parent and/or Guardian authorize Washington Township and its staff to administer medication as described above. In addition to any Waiver and Release signed above, Parent and/or Guardian agrees to release, indemnify, and hold harmless Washington Township and its staff from any lawsuit, claims, expense, demand, or action against them for administering medication in accordance with the instructions provided above.

Release authorized on the dates and/or duration of the registered session.

This release is authorized and executed of my own free will, with the sole purpose of authorizing medical treatment under emergency circumstances, for the protection of life and limb of the named minor child, in my absence.

Please Check *

I reviewed and agree to the terms of this release.

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Confirmation

BY ACKNOWLEDGING AND SIGNING BELOW, I AM DELIVERING AN ELECTRONIC SIGNATURE THAT WILL HAVE THE SAME EFFECT AS AN ORIGINAL MANUAL PAPER SIGNATURE. THE ELECTRONIC SIGNATURE WILL BE EQUALLY AS BINDING AS AN ORIGINAL MANUAL PAPER SIGNATURE.

Parent/Guardian Signature *

Signature Date *

Enter the message as it's shown *

STAFF ONLY: Upload Additional Documentation Here As Needed

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Staff Only Section

WTRC PARTICIPANT MEDICAL FORM 2017

HEALTH PROFILE

AUTHORIZATIONS/WAIVERS

WAIVER AND RELEASE

WTRC PARTICIPANT MEDICAL FORM 2017

HEALTH PROFILE

AUTHORIZATIONS/WAIVERS

**WAIVER AND RELEASE**

WAIVER AND RELEASE