• WTRC PARTICIPANT MEDICAL FORM 2017

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  • Participant Information

  • Parent/Guardian Information #1

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  • Parent/Guardian Information #2

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  • Alternate Emergency Contact Information

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  • Physician Contact Information

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  • HEALTH PROFILE

  • ALLERGIES

  • ANAPHYLAXIS CARE

  • INHALERS

  • IMMUNIZATIONS

  • 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.

  • 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.

  • 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.

  • AUTHORIZATIONS/WAIVERS

  • 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.

  • 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 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.

  • 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.

  • 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.

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  • 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.

  • 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.

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  • **WAIVER AND RELEASE**

  • 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.

  • 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.

  • 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.

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