Zoho Creator - Camper Information Form: Greater Beverly

Camper Information Form: Greater Beverly

Child's First Name *

Child's Last Name *

Birthdate *

Address 1 *

Address 2

City *

State *

Zip Code *

Email Address *

Phone Number *

Sex *

Height *

Weight *

Eye Color *

Hair Color *

Grade Entering Fall 2017 *

Primary Language *

Parent / Guardian Name *

Parent / Guardian Relationship *

Parent / Guardian Email *

Parent / Guardian Cell Phone *

Parent / Guardian Business Name and Phone Number *

Days/Hours at Work (i.e. Monday-Friday 7:00 AM - 3:00 PM) *

Second Parent / Guardian Name

Second Parent / Guardian Relationship

Second Parent / Guardian Email

Second Parent / Guardian Cell Phone

Second Parent / Guardian Business and Phone

Second Parent Days/Hours at Work (i.e. Monday-Friday 7:00 AM - 3:00 PM) *

Emergency Contact Name *

Emergency Contact Relationship *

Emergency Contact Address *

Emergency Contact Home Phone Number *

Emergency Contact Cell Phone Number *

I give permission for my child to be released to this emergency contact *

Second Emergency Contact Name

Second Emergency Contact Relationship

Second Emergency Contact Address

Second Emergency Contact Home Phone Number

Second Emergency Contact Cell Phone Number

I give permission for my child to be released to this emergency contact

Third Emergency Contact Name

Third Emergency Contact Relationship

Third Emergency Contact Address

Third Emergency Contact Home Phone Number

Third Emergency Contact Cell Phone Number

I give permission for my child to be released to this emergency contact

Medical Information:

Child's Doctor's Name *

Doctor's Address *

Doctor's Phone Number *

Insurance Company Name *

Policy Number *

Participating Hospital *

Special Instructions

Does your child have any allergies/special diets/chronic health conditions? *

If yes, what allergies/special diets/chronic health conditions?

Is your child on any medications? *

If yes, which medications? (additional paperwork required for dispensing at camp)

Please print and complete our Authorization to Administer Medication Form. Then, return it to the YMCA with your child's medication.

Possible side effects from medication or special instructions

I certify that I will supply the YMCA with documentation of physical examination and immunizations in accordance with public health department requirements and failure to do so will result in my child not being able to attend camp.

*If you cannot upload your forms at this time, please ensure that you bring them to the YMCA before the start of camp*

Consent *

	Yes, I agree
	No, I disagree
	I will provide at a later date

Please have your doctor fill out our Medical Form, or upload your own documents below.

Medical Form Upload

Local Computer	Google Docs
[Remove] [Remove]

Does your child have an Individual Education Plan (IEP) with school? *

I certify that YMCA camp leadership staff can contact my child's school and/or teacher(s) in order to best accommodate my child's needs if needed.

I give my child permission to go swimming in the Sterling YMCA or Hamilton Community pool. I understand that my son/daughter will be supervised by the summer camp staff, as well as a certified lifeguard.

Consent *

	Yes, I agree
	No, I disagree

I give permission for YMCA staff to put sunscreen/bug spray on my child. I understand that I must provide my child with these supplies. Sunscreen and bug spray are highly recommended since campers are outside.

Consent *

	Yes, I agree
	No, I disagree

I give permission for my child to attend announced field trips. I understand that I will be notified in writing and/or camp newsletters about field trips to various locations. Transportation will be provided by the YMCA of the North Shore and/or Beverly Public Schools.

Consent *

	Yes, I agree
	No, I disagree

I give permission for my child to partipate in regularly schedule Adventure based activities on the Greater Beverly YMCA Challenge Course.

Consent *

	Yes, I agree
	No, I disagree

I have received and reviewed the Sterling YMCA Camp Parent Handbook. I understand and agree to abide by the policies that have been established by the Sterling YMCA. These policies include:

Payment Policy

Pick-up/Drop-off Policy

Swimming Policy

Illness/Medication Policy

Inclement Weather and Emergency Policies

Bug Spray/Sunscreen Policy

Camp Discipline Policy

Consent *

	Yes, I agree
	No, I disagree

My child will arrive to the program by:

My child will depart from the program by:

What should we know specifically about your child so we can provide the best care?

What would you like most for your child to accomplish this summer at camp?

Is there anything else that you feel is important for us to know about your child?

Be sure to read our 2017 Parent Camp Handbook for all the helpful information you need.

I give my child permission to participate in the following activities:

YMCA OF THE NORTH SHORE, INC.

RELEASE AND WAIVER OF LIABILITY/ INDEMNITY AGREEMENT/PHOTO RELEASE

IN CONSIDERATION of being permitted to utilize the facilities, services and programs of the YMCA for any purpose, including but not limited to observation of use of facilities or equipment, or participation in any off-site program affiliated with the YMCA., the undersigned, for himself or herself and any personal representatives, heirs, and next of kin, hereby acknowledges, agrees and represents that he or she has, or immediately upon entering or participating will, inspect and carefully consider such premises and facilities of the affiliated program. It is further warranted that such entry into the YMCA for observation or use of any facilities, or equipment or participation in such affiliated program constitutes an acknowledgement that such premises and all facilities and equipment thereon and such affiliated program have been inspected and carefully considered and that the undersigned finds and accepts same as being safe and reasonably suited for the purpose of such observation, use or participation.

IN FURTHER CONSIDERATION OF BEING PERMITTED TO ENTER THE YMCA FOR ANY PURPOSE INCLUDING, BUT NOT LIMITED TO OBSERVATION OR USE OF FACILITIES OR EQUIPMENT, OR PARTICIPATION IN ANY Off-SITE PROGRAM AFFILIATED WITH THE YMCA.

THE UNDERSIGNED HEREBY AGREES TO THE FOLLOWING:

#1. THE UNDERSIGNED HEREBY RELEASES, WAIVES, DISCHARGES AND CONVENANTS NOT TO SUE the YMCA, its

directors, officers, employees, and agents (hereinafter referred to as “Releasees”) from all liability to the undersigned, his personal representatives, assigns, heirs, and next of kin for any loss or damage, and any claim or demands therefore on account of injury to the person or property or resulting in death of the undersigned, whether caused by the Negligence of the Releasees or otherwise while the undersigned is in, upon, or about (the premises or any facilities or equipment therein or participating in any program affiliated with the YMCA).

#2. THE UNDERSIGNED HEREBY AGREES TO INDEMNIFY AND SAVE AND HOLD HARMLESS the Releasees and each of them from any loss, liability, damage or cost they may incur due to the presence of the undersigned in, upon or about the YMCA premises or in any way observing or using any facilities or equipment of (the YMCA or participating in any program affiliated with the YMCA whether caused by the negligence of the Releasees or otherwise). #3. THE UNDERSIGNED HEREBY ASSUMES FULL RESPONSIBILITY FOR, AND RISK OF BODILY INJURY, DEATH OR PROPERTY DAMAGE due to negligence of Releasee or otherwise while in, about or upon the premises of the YMCA and/or while using the premises or any facilities or equipment thereon or participating in any program affiliated with the YMCA.

#4. The YMCA does not condone staff privately providing child care for program participants. Parents or guardians who hire child care providers from among YMCA staff understand that the YMCA is not responsible for staff who conduct outside employment, and hereby release the YMCA from any liability for acts or omissions of any staff who provide child care outside of YMCA employment.

#5. By signing this Agreement, I hereby give my permission for the YMCA to take my photograph or a photograph of my child(ren) and use or publish this likeness for YMCA purposes, and I release the YMCA from any claims for such use.

THE UNDERSIGINED further expressly agrees that the foregoing RELEASE, WAIVER, INDEMNITY AGREEMENT, PHOTO RELEASE is intended to be as broad and inclusive as is permitted by- the law of the State of Massachusetts and that if any portion thereof is held invalid, it is agreed That the balance shall, notwithstanding, continue in full legal force and effect.

THE UNDERSIGNED HAS READ AND VOLUNTARILY SIGNS THE RELEASE AND WAIVER IF LIABILITY AND INDEMNITY AGREEMENT, and further agrees that no oral representations, statements or inducement apart from the foregoing written agreement have been made.

Signature *

Draw your signature

Clear

Please note: For your ease, you only need to fill out one form per camper.

Upgrade Now

(Or) Cancel