Please carefully read each of the following authorizations and permission statements; initial & sign in the spaces below to indicate your acknowledgement and acceptance of the outlined terms and conditions. - SPARK - Manchester

RELEASE AUTHORIZATION: I authorize the Wabash County YMCA to release my child(ren) to the person(s) indicated above. I also give consent to those listed above to act on my behalf in an emergency in the event that I cannot be reached. I understand that my child(ren) will not be allowed to leave the program with an unauthorized person. Additionally, any authorized person picking up my child(ren), including parents, must present a valid picture I.D. Should an authorized person arrive to pick up my child(ren) that appears to be under the influence of alcohol or drugs, the staff will report this person to the police. I understand that YMCA staff and volunteers are not allowed to babysit children at any time outside the YMCA Program or transport children in their own vehicles. The YMCA will take immediate disciplinary action toward staff and volunteers if a violation is discovered.

PARENT AUTHORIZATION: I hereby declare that my child(ren) to be physically sound, having medical approval to participate in the activities of the Wabash County YMCA. The health information provided above is correct as far as I know, and the person herein described has permission to engage in all prescribed program activities except as noted. I further understand that neither the YMCA nor any of its paid staff or volunteer workers can be held responsible in the event of an accident.

EMERGENCY AUTHORIZATION: I understand that Wabash County YMCA Staff are trained in the basics of first aid and CPR and give consent to have my child receive first aid from Wabash County YMCA Staff. I authorize the Wabash County YMCA to secure emergency medical treatment for my child, if necessary, provided that every effort to reach me is made as the nature of the emergency permits. I hereby give permission to the medical personnel selected by the program director to order X-rays, routine tests and treatment for my child(ren), and, in the event I am not able to communicate or cannot be reached in an emergency, I hereby give permission to the physician selected by the program director to hospitalize, secure proper treatment for, and order injection(s) and/or anesthesia and/or surgery for my child(ren) as named above. I accept responsibility for any all expenses incurred in securing emergency treatment for my child, even if not covered by insurance. I also agree to waive any claims against the Wabash County YMCA, its members, staff, and volunteers for injuries or damages that may result  from the conduct of other persons including participants in YMCA Programs. I understand that the Wabash County YMCA does not cover health and medical expenses and I agree to pay any that may occur.

DATA RELEASE: I give my child permission to participate in the Wabash County YMCA SPARK Program, including the evaluation process.  I understand that this process includes collection of demographic data, attendance, academic outcomes and youth development outcomes. I agree that the Wabash County YMCA, YMCA of the USA, and anyone they give permission to, has the right to use my child’s school data and my survey responses in any form or manner whatsoever and that I will have no objection to this now or in the future. I understand and agree that the data and survey responses may be used as part of another work made by YMCA of the USA or others and that YMCA of the USA may provide this work to others as well. No information about my child will be disclosed to anyone outside the research process. The research staff will maintain my child’s confidentiality by not revealing his/her name through any material or data.  

PARENT OR GUARDIAN PERMISSION: My signature below indicates that I have legal authority to register the child(ren) named on this form and that to the best of my knowledge the information on this registration form is complete and accurate. I further understand that all necessary health, security and waiver forms must be signed and on file with the Wabash County YMCA prior to my child(ren) attending the program(s). Failure to comply with the above could result in the loss of your child(ren)’s spot in the program(s).

 

PARENT STATEMENT OF UNDERSTANDING: I have read and understand the policies listed below:

• I understand that, when my child(ren) arrives in the morning, I may not leave my child(ren) at the program site unless I have signed in with the Wabash County YMCA Staff person and that I (or any other adult authorized to pick up my student) will not be permitted to sign my student out of programming without first showing a valid picture I.D.
•  I give permission for the Wabash County YMCA to photocopy all forms.
•  I understand that I am responsible for following the policies and procedures outlined in the specific program guidelines including parent manuals when one exists. If I fail to meet my obligation to the program policies, the Wabash County YMCA reserves the right to suspend my child(ren)’s participation in the program.
• I understand that Wabash County YMCA Staff is mandated by state law to report any suspected cases of child abuse or neglect to appropriate authorities for investigation.
• I understand that the Wabash County YMCA is not responsible for any lost, damaged, or stolen articles.