Fillable Mankato Family YMCA Summer Camp 2021 School-Age Registration

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Mankato Family YMCA Summer Camp 2021 School-Age Registration

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Page 1/4 ONLINE DOWNLOAD
Mankato Family YMCA Summer Camp 2021
School-Age Registration Form
Staff Initial
Water Bottle
CAMPER NAME PHONE BIRTH DATE
ADDRESS CITY ZIP
AGE AT CAMP SCHOOL GRADE IN FALL (21) GENDER: M F
MOTHER/GUARDIAN NAME: DAYTIME PHONE:
FATHER/GUARDIAN NAME: DAYTIME PHONE:
EMAIL ADDRESS
IN CASE OF ACCIDENT OR ILLNESS NOTIFY
(Parents will be notied rst, please list an alternative contact):
NAME RELATIONSHIP PHONE #’s
Please list below individuals whom you give your permission to pick up your child on any given day
without prior notication:
Names & Relationship:
Is there anyone whom you do not wish to pick up your child under any circumstances?
Check One:
Y N
If you have a court order prohibiting contact by a parent, include a copy with your paperwork
Name & Explanation:
Extended Care
Extended Care will not be offered for Summer Camp 2021
My child will
eat HOT LUNCH
Please select a lunch preference:
*Hot lunch may not be available June 7-11;
watch for more information
My child will bring
a SACK LUNCH
CIRCLE
YOUR
CAMPS
June
7-11
June
14-18
June
21-25
June 28
- July 2
July
5-9
July
12-16
July
19-23
July
26-30
Aug
2-6
Aug
9-13
Aug
16-20
Kindergarten
Clubhouse
Explorers
Voyagers
Pre-Teen
Sports Camp
Equestrians
Camps
Chesley
Skateboarding
LIT & CIT
*Sunday-Friday
Camp
Patterson
1
HC 1
Gr 2-5
HC 2
Gr 2-5
HC4
Gr 6-8
HC 5
Gr 2-5
HC 6
Gr 2-5
1
Gr 1-5
2
Gr 6-8
3
Gr 1-5
4
Gr 1-5
5
Gr 1-5
1 LIT
2 LIT
3 LIT
1 CIT
2 CIT
3 CIT
1
June
13-18
2
June
20-25
3
Aug
1-6
1
2
3
4 4 4
5 5 5
6 6 6
7 7 7
8 8 8
9 9 9
10 10 10
11 11 11
Flag
Football
Gr 2-5
Dance
Gr 2-5
Soccer
Gr 2-5
SPLASH
Gr 6-8
Basketball
Gr 2-5
Mulit-
Sports
Gr 2-5
STRIDE
Gr 3-5
1 1
2
3
2
2
3
5
4
6
7
8
3
SCHOOL AGE DAY CAMPS
RESIDENT
CAMP
Gr 3-7Gr 1-8 Gr 6-8Gr 2-8Gr 2-8Gr 4-5Gr 1-3ENT K
Gr 8-12
SUMMER
CAMP
MANKATO FAMILY YMCA
2021
*RESIDENT CAMPERS ONLY
Are there any cabin mate requests?
If yes, please list
Should your child be given a lower bunk bed
because of restless sleeping, bedwetting,
medication, etc?
Check One:
Yes No N/A
Explain:
HC 3
Gr 2-5
Volleyball
Gr 2-5
Page 2/4
2. HEALTH
Does child suffer from any allergies (medication, food, insect stings, other)?
Check One: YES NO
Please list and describe the reaction and management.
Has child ever been stung by a bee?
Check One: YES NO
If Yes, explain reaction:
Has child had a recent illness or been exposed to a contagious illness?
Check One: YES NO
If Yes, explain reaction:
Are child’s immunizations up to date as required by the State Health Dept?
Check One: YES NO
If not, please indicate reason:
Is child well enough to take part in all activities?
Check One: YES NO
If no, explain:
Does child have any physical disabilities?
Check One: YES NO
If yes, please describe:
Does child have any mental or emotional difculties which staff should be aware of?
YES NO
If yes, please describe the main issues and any solutions:
3. SWIMMING SAFETY
Students will periodically participate in Free Swim (not swim lessons) at the Mankato Family YMCA. It will be helpful to our
staff to know more about your child’s swimming ability so that we can make the swimming experience as safe as possible for
all involved. Please take a moment to complete this survey.
Beginner Swimmer
Intermediate Swimmer
Advanced Swimmer
Swim under water
Swim length of the pool
Tread water for 1 minute or more
I consider my child to be a (check one) S/he can (check all that apply)
My child is participating in
Chesley Skate Programs
and is exempt from
swimming portion.
1. MEDICATION
Will youth need medication during the hours of programming?
Check One: YES NO
A. PARENT/GUARDIAN AUTHORIZATION FOR PRESCRIPTION MEDICATION :
If child is to receive prescription medication during programming, please complete the following and sign:
Prescribing Physician Clinic Phone
Medication Dosage & Time:
Instructions for giving medication
Diagnosis/Medical reason for medication
B. PARENT/GUARDIAN AUTHORIZATION FOR NON-PRESCRIPTION MEDICATION
If non-prescription medication is being sent with child please complete and sign:
Medication Purpose for giving medication:
Amount to be given Frequency
Page 3/4
Mankato Family YMCA Program Behavior Expectation, Policy Guidlines
and Participant Agreement
NOTICE: THIS IS A LEGALLY BINDING AGREEMENT. Read the following carefully and in entirety. By signing this agreement, you have read and
agree to follow all Mankato Family YMCA and Chesley Skate Park policies and guidelines and you have read and fully understand the Liability
Agreement. You agree to give up your right and the named minor’s right to bring a court action to recover compensation or obtain any other
remedy for any personal injury or property damage however caused arising out of the named minor’s participation in YMCA Programs, now or
any time in the future.
Policies & Guidelines
1. I authorize the YMCA to obtain emergency medical treatment for my child in case of sudden illness or accident. I give permission
to the medical personnel selected by the YMCA to order x-rays, routine tests, and to secure and administer treatment, including
hospitalization; releasing any records necessary for insurance purposes; and to provide or arrange necessary transportation.
2. If non-prescription/prescribed medication is to be given during YMCA program I herby authorize the YMCA staff to administer this
medication. I release YMCA personnel from any liability in relation to the administration of this medication and understand I must
provide this medication in the original, properly labeled bottle/container with enough to last the duration of the program session.
3. I agree to the stated Behavior Expectation Policy and understand that I will not receive a refund if my child is suspended or
dismissed.
4. I authorize the reproduction, publication, and use by the YMCA for promotion, public relations, or social media use of any picture or
video footage of my child taken in this program. (Program Guide, Flyers, Ads, YMCA Website, Facebook, Instagram).
If no, explain: _________________________________________________________________________________________________________________________________________________________
Parent/Guardian Signature
Today’s Date
Behavior Expectation:
The Mankato Family YMCA staff works proactively with your camper to follow the mission of the YMCA of the USA: “To put Christian
principles into practice through programs and services that build healthy spirit, mind and body for all” as well as apply the five core values
of Caring, Honesty, Respect, Responsibility and Faith. We expect all campers to treat others with these principles and values in mind. If a
camper’s behavior deems unsuitable for camp, we will respond with those same principles.
The YMCA does not tolerate physical fighting, inappropriate language and/or touch, disruptive behavior, profanity, blatant disrespect,
violation of rules or illegal activity. If this should occur, parents will be notified and may be asked to pick up their child, dependent on the
circumstances. If behaviors continue or escalate, the child may be suspended from the program depending on the severity and/or frequency
of behavior. Our goal is to provide positive growth opportunities for all in a safe, healthy, nurturing environment. Refunds will not be given
if a child is sent home because of a behavioral problem.
Chesley Skate Park
1. I acknowledge that my participation in skateboarding, in-line skating, BMX bicycling, scooters, or other activities or sports known as
dangerous but not mentioned above entails known and unanticipated risks that could result in physical or emotional injury, paralysis,
death, or damage to myself, to property, or to third parties. I understand that such risks simply cannot be eliminated without
jeopardizing the essential qualities of the activity. The risks include, among other things: Collision with other participants, the walls,
or other xed objects; falling down; my own equipment failure or the failure of others’ equipment; my own or others’ negligence; and
objects or conditions on the surface that may cause me to fall; broken bones, sprains, head and back injuries, abrasions, and bruises.
Furthermore, YMCA Chesley Skate Park employees have difcult jobs to perform. They seek safety, but they are not infallible. They might
be unaware of a participant’s tness or abilities. They may give inadequate warnings or instructions, and the equipment being used
might malfunction.
2. I expressly agree and promise to accept and assume all of the risks existing in this activity. My participation in this activity is purely
voluntary, and I elect to participate in spite of the risks. I expressly agree and promise to wear a helmet at all times during any activity I
participate in at the YMCA Chesley Skate Park.
3. I hereby voluntarily release, forever discharge, and agree to indemnify and hold harmless YMCA Chesley Skate Park from any and all
claims, demands, or causes of action, which are in any way connected with my participation in this activity or my use of YMCA Chesley
Skate Park equipment or facilities, including any such claims which allege negligent acts or omissions of YMCA Chesley Skate Park.
4. Should YMCA Chesley Skate Park or anyone acting on their behalf, be required to incur attorney’s fees and costs to enforce this
agreement, I agree to indemnify and hold them harmless for all such fees and costs.
5. I certify that I have adequate insurance to cover any injury or damage I may cause or suffer while participating, or else I agree to bear
the costs of such injury or damage to myself. I further certify that I am willing to assume the risk of any medical or physical condition I
may have.
6. I agree that if any portion of this agreement is found to be void or unenforceable, the remaining portions shall remain in full force and
effect.
In consideration of participant being permitted by YMCA to participate in its activities and to use its equipment and facilities I hereby certify
and agree to all of the terms of the above Release and Assumption of Risk provisions on behalf of said minor and myself. I further agree to
indemnify and hold harmless Mankato Family YMCA from any and all claims which are brought by, or on behalf of Minor, and which are in any
way connected with such use or participation by said minor. I have read, understand and agree to the policy, guidelines and participation
agreement statements above.
Page 4/4
Parent/Guardian Signature
Parent/Guardian Phone Number
Participant Name (Print Clearly) Participant Birthdate Today’s Date
Parent/Guardian Name (Print Clearly)
Mankato Family YMCA Minor Participant Waiver, Release,
Indemnication of All Claims & Covenant Not to Sue
PLEASE READ CAREFULLY. THIS DOCUMENT AFFECTS YOUR LEGAL RIGHTS AND IS LEGALLY BINDING.
BY SIGNING THIS AGREEMENT YOU ARE RELEASING MANKATO FAMILY YMCA FROM ALL LIABILITY AND
FOREVER GIVING UP ANY CLAIMS THEREFOR
Assumption of Risk
I, in my legal capacity as parent/guardian of the minor named below (“Minor”), acknowledge and agree
that any use of Mankato Family YMCA facilities, services, equipment and premises (“Facilities”) and any
participation in Mankato Family YMCA programs and activities (“Programs”) comes with inherent risks
including, but in no way limited to: (1) moderate and severe personal injury, (2) property damage, (3) dis-
ability, (4) death, and (5) sickness or disease. I voluntarily, for myself and Minor, accept and assume full
responsibility for these risks as well as any and all other risks of the use of Facilities and participation in
Programs. I agree that I have full knowledge of the nature and extent of all such risks and am not relying
on all such risks being described in this document.
Waiver, Release, Indemnication & Covenant Not to Sue
In consideration of Minor’s use of Facilities and participation in Programs I, in my legal capacity as
parent/guardian of Minor, agree on behalf of myself and Minor that Mankato Family YMCA its ofcers,
directors, agents, employees, volunteers, insurers and representatives (“Releasees”) will not be liable for
any personal injury, property damage, disability, death, sickness or disease incurred by Minor, however
occurring including, but not limited to, the negligence of Releasees. I understand that Minor and I will be
solely responsible for any loss or damage, including personal injury, property damage, disability, death,
sickness or disease sustained from the use of Facilities and participation in Programs.
I further agree, in my legal capacity as the parent/guardian of Minor, on behalf of Minor, myself, and any
and all legal successors and proxies, to release and HEREBY DO RELEASE, WAIVE AND COVENANT NOT
TO SUE Releasees from any causes of action, claims, suits, liabilities or demands of any nature whatso-
ever including, but in no way limited to, claims of negligence, which Minor, myself, and any and all legal
successors and proxies may have, now or in the future, against Releasees on account of personal injury,
property damage, disability, death, sickness, disease or accident of any kind, arising out of or in any way
related to the use of Facilities or participation in Programs, whether that participation is supervised or
unsupervised, however the injury or damage occurs, including, but not limited to, the negligence of Re-
leasees.
In further consideration of the use of Facilities and participation in Programs, I, in my legal capacity as
parent/guardian of Minor, agree on behalf of myself and Minor to INDEMNIFY AND HOLD HARMLESS
Releasees from any and all causes of action, claims, demands, losses, suits, liabilities or costs of any na-
ture whatsoever, including claims of negligence, arising out of or in any way related to the use of Facili-
ties and participation in Programs.
YMCA Horse Camp
RELEASE AND WAIVER OF LIABILITY,
ASSUMPTION OF RISK AND INDEMNITY AGREEMENT
READ THIS AGREEMENT CAREFULLY BEFORE SIGNING IT. YOUR SIGNATURE INDICATES YOU
UNDERSTAND IT AND AGREE TO ITS TERMS. BY SIGNING THIS AGREEMENT, YOU AND YOUR CHILD ARE
GIVING UP CERTAIN LEGAL RIGHTS, INCLUDING THE RIGHT TO SUE OR RECOVER DAMAGES IN CASE OF
INJURY, DEATH OR PROPERTY DAMAGES, FOR ANY REASON, INCLUDING BUT NOT LIMITED TO ACTS OF
THE STABLE, ITS OWNER, EMPLOYEES AND AGENTS (THE “RELEASEES”).
I, _______________________________________ represent myself and my minor child ________________________________
[Print First and Last Name] [Print Child’s Name]
I reside at _____________________________________ in __________________________, __________, _________________ .
[Street Address] [City] [State] [Zip Code]
In consideration for allowing my minor child to handle and ride a horse and on behalf of myself, my child or our personal
representatives, heirs, next-of-kin, spouses and assigns, I HEREBY:
1. Acknowledge that a horse may, without warning or any apparent cause, buck, stumble, fall, rear, bite, kick, run, make
unpredictable movements, spook, jump obstacles, step on a person’s feet, push or shove a person, and saddles or bridles may
loosen or break - all of which may cause the rider to fall or be jolted, resulting in serious injury or death.
2. Acknowledge that horseback riding is an inherently dangerous activity and involves risks that may cause serious injury and
in some cases death, because of the unpredictable nature and irrational behavior of horses, regardless of their training and past
performance.
3. Voluntarily assume the risk and danger of injury or death inherent in the use of the horse, equipment and gear provided to
my child by Pinewood Stable.
4. Release, discharge and agree not to sue Pinewood Stable and/or any of its owners, employees or agents (hereinafter, the
“Releasees”), for any loss, liability, damages, or cost whatsoever arising out of or related to any loss, damage, injury or death to
my person or property.
5. Release the Releasees from any claim that such Releasees are or may be negligent in connection with my child’s riding ability
or experience, including but not limited to training or selection of horses, maintenance, care, fit or adjustment of saddles or
bridle, instruction or riding skills or leading and supervising riders.
6. Indemnify, and save and hold harmless Pinewood Stable, its riding instructors, its employees and agents from and against any
loss, liability, damage or cost they may incur arising out of or in any way connected with either my use or my minor child’s use
of the horse and any equipment provided or any acts or omissions of its riding instructors or other employees or agents.
7. The Undersigned expressly agrees that the foregoing release and waiver of liability, assumption of risk and indemnity
agreement is governed by the State of Minnesota and is intended to be as broad and inclusive as is permitted by Minnesota
law, and that in the event ay portion of this agreement is determined to be invalid, illegal, or unenforceable, the validity, legality
and enforceability of the balance of the agreement shall not be affected or impaired in any way and shall continue in full legal
force and effect.
8. Acknowledge that this document is a contract and agree that if a lawsuit is filed against Pinewood Stable or it owners, agents,
riding instructors or employees for any injury or damage in breach of this contract, the Undersigned will pay all attorney’s fees
and costs incurred by Pinewood Stable in defending such an action.
9. State that my child is not physically incompetent to participate in horse riding activities. My child does not have a history
of epileptic seizures, heart condition or any other medical condition that could be affected by horseback riding.
I have read this entire Release of Liability Document. I understand it is a promise not to sue and to release Pinewood Stable, it’s
owners, riding instructors, employees and agents for all claims. I have made a free and deliberate choice to sign this Release and
Waiver as a condition to Pinewood Stable allowing me or my child to ride or handle a horse. I have concluded that the risks
involved and the release and waiver of liability is worth the opportunity to take horse riding lessons and the pleasure of the
horseback riding experience.
__________________________ ___________________________________________________
[Date] [Signature]
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Mankato Family YMCA Summer Camp 2021 School-Age Registration

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Completed 29 April 2021

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