Participant Name
*
First Name
Last Name
Main Phone Number of Participant
*
(###)
###
####
Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Birthdate of Participant
*
MM
DD
YYYY
Gender
*
Male
Female
Prefer not to say
Name of GUARDIAN
(If participant is under the age of 18 at time of registration)
First Name
Last Name
Emergency Contact Name
*
First Name
Last Name
Relationship to the Participant
*
Phone # for Emergency Contact
*
Please choose the best phone number to call in case of an emergency.
(###)
###
####
Health Care Number
*
Participant has a history of feeling faint, spells of dizziness or seizures?
*
Yes
No
Participant has a history of epilepsy?
*
Yes
No
Participant is subject to one of the following:
*
Please check all that might apply or choose, "None of the above".
Please list any allergies (may include medications, food or other):
*
If there are none, please type, "NONE".
Does participant have any conditions, not covered above, which may affect participation or need treatment in an emergency:
*
No
Yes
If yes, please use this space to explain:
Please mark any diseases participant has had previously:
*
Check all that apply
Tetanus
*
MM
DD
YYYY
Polio
*
MM
DD
YYYY
Is participant under any special medical or dietary regime to be continued on an outing?
*
Yes
No
If you chose "Yes", please explain.
Will participant bring any medicine with them?
*
Yes
No
Not Applicable
If you chose "Yes", please provide the name of the medication and any pertinent information or precautions we should be aware of:
Are there factors that might limit participant’s full participation in activities?
*
Yes
No
If you chose "Yes", please explain:
Name of Doctor/Clinic
*
First Name
Last Name
Doctor's Office/Clinic Phone Number
*
(###)
###
####
I HAVE READ THE ABOVE AND I UNDERSTAND ITS MEANING. Please enter today's date:
*
MM
DD
YYYY
Please re-enter Name of Participant or Guardian (if Participant is under the age of 18 years of age)
*
PLEASE NOTE THAT BY FILLING OUT THIS FORM AND BY ENTERING YOUR NAME, THIS IS CONSIDERED YOUR DIGITAL SIGNATURE AND ACCEPTANCE OF OUR RULES OF CONDUCT.
First Name
Last Name
(a) acknowledge that involvements in and access to some or all of these functions may involve transportation private and/or public; (b) understand that these functions and transportation to and from these functions may involve some risks, including the risk of physical injury; (c) understand that unintended injuries and death may possibly result as a consequence of participation in such functions and transportation to and from these functions; (d) accept full risk and responsibility for the death of or injury to the Participant or damage to the property of the Participant arising from the functions or transportation to and from such functions by the Participant; (e) waive any rights whatsoever that the undersigned may have now or in the future against YU/YFC and, as applicable, its members, directors, officers, leaders, agents, volunteers and/or employees as a result of death or injury to the Participant or damage to the property of the Participant arising from the participation in the functions or transportation to and from such functions undersigned; (f) release and forever discharge YU/YFC, its members, directors, officers, leaders, volunteers, agents and /or employees from all actions, causes of action, suits, claims and demands whatsoever, that may arise from any functions or transportation to and from such functions, however caused: (g) agree and understand that this document will be binding on the heirs, executors, administrators and assigns of the undersigned, parents/guardians and the Participant; (h) agree to indemnify and hold harmless YU/YFC, its members, directors, officers, leaders, agents, volunteers and/or employees from any actions, suits, claims, demands whatsoever, arising from any negligent, wrongful or illegal act or omission of the Participant in respect of any function or transportation sponsored, arranged or coordinated by YU/YFC or its agents; and (i) agree that if any provision hereof is invalid, illegal, or incapable of being enforced by reason of any rule of law or public policy then such provision will be severed from and will not affect any other provision contained herein, and this instrument will be read as if such invalid, illegal or unenforceable provision had never been contained herein and all other provisions hereof will, nevertheless, remain in full force and effect and no provision will be deemed to be dependent upon any other provision. (j) give permission to YFC/Youth Unlimited to obtain personal information about the participant for the purposes of communications and registration requirements. (k) give permission for the participant's photo to be taken and used in the communication and promotion of YFC/Youth Unlimited events.
I HAVE READ THE ABOVE AND I UNDERSTAND ITS MEANING.
*
No
Yes - this is considered to be your digital acceptance of the above
Please enter your name again to state you have read the above and are in agreement,
*
First Name
Last Name
If there is anything else that should be included in this form, please use this space.
This Participant Waiver and Medical Release Form is inclusive of all Youth Unlimited events that the above student is a participant of, (such as, but not limited to: camps, mission trips, hikes, tours, event outings) for one calendar year from the date of this form submission.
I DO NOT Agree to this Waiver
I AGREE to this Waiver
