Convulsions Yes □ No □ Bladder/Kidney Trouble Yes □ No □
Fainting Yes □ No □ If yes explain: ______________________________________________
Asthma/Wheezing Yes □ No □
Hearing Problems Yes □ No □ _________________________________________________________________
Ear Infections Yes □ No □
Rheumatic Fever Yes □ No □ Recent Surgery: Yes □ No □
Diabetes Yes □ No □ If yes explain: _______________________________________________
Glasses/Contacts Yes □ No □
Hearing Aids Yes □ No □ __________________________________________________________________
Artificial Limbs Yes □ No □
Other Allergy Yes □ No □
If yes, what: __________________________
Does child receive any type of medication? Yes □ No □
CONSENT ITEMS
(Parent/legal guardian initials required on EACH LINE below.)
1. Obtaining Emergency Medical Care: ______________ 5. Minor First Aid Care: __________________
2. Special Events Participation: ____________________ 6. Receipt of Parent Packet: _____________
3. Administration of Medication: ____________________
4. Inclusion of photos for promo: ___________________
To the best of my knowledge, all of the information provided is true; and I have listed all warnings and restrictions. I believe my child is in
good health and able to participate in all activities, unless otherwise specified. The YMCA has my permission to obtain proper medical
treatment for my child in the event of an emergency. I hereby agree to indemnify and hold harmless the YMCA of Indiana County, its staff
and volunteers from losses, claims or actions that mar arise from any act, omission, event or incident of any nature, occurring while my child
is engaged in any reasonable and normal activity sponsored by the YMCA. I have read the Childwatch Policies and Procedures Parent
Handbook. I understand that in order to use the services of Childwatch, I must pre-register my child(ren) every session by the indicated time
deadline for each session. I understand that the only ways to cancel my child(ren) is to email childwatch@icymca.org, cancel online through
the YMCA website or stop at the Welcome Center. I understand the content of this handbook may be changed at any time.
YMCA of INDIANA COUNTY WAIVER AGREEMENT PLEASE READ CAREFULLY BEFORE SIGNING.
THIS IS A RELEASE OF LIABILITY AND THE WAIVER OF CERTAIN LEGAL RIGHTS.
THE UNDERSIGNED PERSON hereby acknowledges intent to participate with the YMCA of Indiana County activities. The undersigned freely
and unconditionally waives and releases the YMCA and any and all of its employees, representatives and agents and their successors and
assigns (the “YMCA of Indiana County”) from all liability and/or claims of the Undersigned, his personal representatives, and/or his estate for
any and all loss or damage and/or claims of demands due to personal injury as result of my physical condition or resulting from my
participation in any athletic activities, YMCA programs led by staff or volunteers, and the use of any equipment, exercise or other activities.
The Undersigned further agrees to defend, indemnify and hold the YMCA harmless from and against any and all liabilities, demands, claims,
damages, suits, judgments and decrees, and court awards including costs, expenses and attorneys’ fees, on account of injuries to or death
of any person or persons or damage to any property arising out of or related to the Volunteer’s intentional or negligent acts, errors or
omissions for the duration of the Undersigned’s participation. I understand that the YMCA of Indiana County is not responsible for personal
property lost or stolen while members and/or program participants are using YMCA facilities or on YMCA premises.
I HAVE CAREFULLY READ THE FOREGOING WAIVER, UNDERSTAND ITS CONTENTS, AND AM AWARE THAT I AM RELEASING CERTAIN LEGAL
RIGHTS. I ACKNOWLEDGE THAT I AM SOLELY RESPONSIBLE FOR ANY INJURIES INCURRED WHILE PARTICIPATING WITH THE YMCA.
I certify that the information contained in this application is true and correct to the best of my knowledge. I have read the waiver
agreement, understand it’s content, and acknowledge that I am responsible for any injuries encountered while participating, except for those
caused by the negligence of the YMCA of Indiana County.
I understand that I and all the individuals in my membership unit can find all the membership policies and agreements, including the code of
conduct, in the Member Handbook. I can request a printed copy of this handbook at any time at the Welcome Center. I understand that by
signing this form I will adhere to all policies set in the above listed forms.
Parent/Legal Guardian Signature: ____________________________________________________________________________________ Date: _____________________________________