Camp Parent Guide PDF - YMCA of Silicon Valley

YMCA Camp CampbellCampo de los Niños Parent Guide 2011WHAT’S INSIDE?Page 2 Bus InformationDriving to Camp/DirectionsCheck-In/Check-Out DetailsPage 3 Preparing for CampPacking ListHealth History & Waiver Forms, MedicationsPage 4 Your Child’s Stay at YMCA Camp Campbell:Leadership, HomesicknessKeeping in Touch, Health Care at CampEmergency Contact InfoPage 5 Behavior at CampPayment and Refund DetailsInsurance, Licensing and AccreditationPage 7 Summer Camp Preparation Check ListPage 8 All necessary forms

GETTING TO CAMPDriving to Camp?We encourage parents to bring their childrento camp. This provides an opportunity tomeet your child’s cabin leader and to see ourfacilities.Bus TransportationIf you cannot bring your child to and fromcamp and need help with transportation,we are offering one-way bus transportationfor an additional $25 on Sunday, August 7,and Saturday, August 13. Sign up for bustransportation on the enclosed registrationform or call 831-338-2128 in advance toreserve your child’s spot. You must register forthe bus at least 48 hours before departure onSunday and Saturday.If you’ve already paid for bus transportation,please send proof of payment to 831-338-9486(fax) or redwoods@ymcasv.org (email).Taking the Bus to Camp?After you’ve registered your child for bustransportation at least 48 hours in advance,you’ll need to check in at Central YMCA at12:30 pm on Sunday, August 7.Central YMCA is located at:1717 The Alameda, San Jose, 95126The bus will depart from Central YMCA at 1pm. There will be no exceptions for late checkinto ride the bus.Taking the Bus Home?The returning bus from camp (16275 Highway9, Boulder Creek, CA) will arrive at CentralYMCA between 11:00 and 12:30 pm onSaturday, August 13. Traffic on the mountainroads can be unpredictable. If any changesoccur, we will call in details to Central YMCAat 408-298-1717. Please bring a Photo ID tocheck out your child at the bus return. We willonly release children to parents or authorizedindividuals. If your child is to be picked upby someone other than a parent, be sureto include that person’s name on the healthhistory form. *If court orders concerning childcustody are in effect, please notify us with awritten note prior to arrival at camp.DirectionsYMCA Camp Campbell is located on Highway 9,three miles north of the town of Boulder Creek.Highway 9 can be accessed from Saratoga viaSaratoga Ave. or in Felton off the Highway 17freeway.Take Highway 17 south from San Jose or northfrom Santa Cruz to the Mount Hermon Roadexit and follow Mount Hermon to Felton.In Felton, take a right onto Graham Hill Road,then after that an immediate right ontoHighway 9, which will take you to the town ofBoulder Creek.Continue through Boulder Creek on Highway 9.YMCA Camp Campbell (16275 Highway 9,Boulder Creek, CA) will be on the left, threemiles past the town of Boulder Creek.Check-in at CampCheck-in at YMCA Camp Campbell begins at2:00 pm on Sunday, August 7. Please do notarrive any earlier than that, as our staff arevery busy preparing for the start of camp.Last check-in is at 3:05 pm. Our hope is tohave all campers ready to start their campingexperience no later than 3:15 pm. Please helpby arriving during these times.Check-out at CampCheck-out at camp begins at 10:00 am onSaturday, August 13. Be sure to pick up yourchild no later than 11:00 am. Please bring aPhoto ID to check out your child (at camp or atthe bus stop). We will only release children toparents or authorized individuals. If your childis to be picked up by someone other than aparent, be sure to include that person’s nameon the health history form. *If court ordersconcerning child custody are in effect, pleasenotify us with a written note prior to arrival atcamp.Page 2

Preparing For CampPacking Listo Sleeping bag/beddingo Pillowo Sweatshirt and/or jacketo T-shirts (6)o Long pants (2-3)o Shortso Underwear (7)o Socks (7 pairs)o Shoes (2 pairs)Must wear closed toe shoes.o Flip flops (for shower time)o Pajamaso Swim gearo Hat or capo Towelo Toiletrieso All insulin pump suppliesMust be labeled with name.o All necessary medications such as thyroidmeds/ inhalers/ ADD medicationOver-the-counter drugs such as Tylenol are providedas needed.o Chapsticko Sun blocko Water bottleMust bring water bottle labeled with nameo Backpacko Flashlighto Camera (disposable is best)o Positive attitudePlease label all of your child’s belongings.Lost and found will be displayed on the last dayof camp. We will hold lost and found items foronly two weeks at camp after the session ends.Not permittedElectronics including cell phones, food orcandy, knives/firearms, weapons, fireworks,personal recreation equipment, pets, aerosolsprays, hair dryers, curling irons, money,alcohol/drugs, cigarettes, personal meters/remote control meters, insulin pens.Ipod/Game Boy may only be used at quiet timewith earphones and must be name labeled.Page 3Health History Form and Liability WaiverYou must complete a health history form andmail it to the camp office immediately for yourchild to attend camp. We cannot acceptany campers without this form. Schedule adoctor’s examination for your child if they havenot had one within the 18 months prior to comingto camp. Please have your physician fill out theproper sections on the health history form.Once completed please fax the form to831-338-9486 or email to redwoods@ymcasv.org. It is very important that you provide uswith complete emergency contact informationon the Health History Form. If you are travelingduring your child’s stay at camp, please liston the form an itinerary and phone numberswhere you can be reached. A Liability Waiver isalso required for each camper.MedicationPlease do not pack any medications (includingover-the counter drugs) in your child’sluggage. All medications must be submittedto YMCA health care staff either at YMCACamp Campbell or to the camp counselorsduring bus pick-up. Prescription drugs mustbe in the original container with a licensedphysician’s instructions. Please place yourpackaged medications in a clearly labeled ziplockbag along with dosage and directions foradministering. Place your child’s name on theoutside of the bag. Masking tape works wellfor labeling. All medications are administeredby the camp health staff under doctor’s orparents’ written orders. Unused medicationswill be returned at the close of the campsession. Drugs for which we do not receivewritten authorization to administer will not beprovided by the health staff, including Tylenolor Ibuprofen.

Your Child’s Stay at ymca Camp CampbellLeadershipCabin groups of eight to 12 campers aresupervised by at least one experiencedcamp leader. All staff are selected for theirwillingness to work with children and undergoa training program prior to the beginningof summer camp. Character reference andbackground checks are conducted for allpositions. Our camp staff and coordinatorshave extensive experience in camp leadership.Our camp program is supervised by aprofessional YMCA Director. We put a greatdeal of effort into finding the finest people tolead and inspire our campers.HomesicknessGoing away to camp for several days can bea challenging experience for many children.Short-term separation from parents andlearning independence are part of growing up,even though it may not always be easy. Manychildren have some difficulty coping with thechanges that come with spending a week awayfrom home. This anxiety is perfectly normaland happens on occasion.We would like to ask your help in counselingyour children prior to camp in order to makethe transition easier. Let them know that youhave confidence in their ability to be away fromfamily and how exciting it will be to meet newfriends. If they are unsure of themselves, letthem know how proud you will be of them ifthey try their best to succeed.While your child is at camp we will notify you ifany concerns arise.Once at camp, we do not allow phone calls tohome directly from the campers. Often, whena homesick child speaks to someone fromhome, their homesickness is only made worse.Instead we encourage letter-writing both toand from the family. You may even wish tomail a letter a few days prior to the session tomake sure that it arrives while your child is atcamp. On our end, we will keep the campersso busy having fun that they may even forgetabout their homesickness entirely.Keeping in TouchSend mail to your camper to:Camper’s Name Session #, Cabin #YMCA Camp Campbell16275 Hwy 9Boulder Creek, CA 95006Campers love to receive mail and areencouraged to write home. Sending anenvelope/post card that is self-addressed andstamped is an excellent idea. When sendingmail, please allow two-to-three days for itto arrive at camp. Please do not send anypackages with food or candy.Health Care at CampOur camp has a well-equipped health centerwith resident health care staff. In case ofillness, your child will be housed in the healthcare facility for a reasonable period of time.If deemed necessary, you will be contacted topick up your child. If your child is ill, pleasedo not send him or her to camp. We will try toreschedule for another week. In case of injury,our health care staff will take the necessarymeasures to ensure proper emergency care,which may include treatment for minorinjuries, calling the parents for instructions orcalling local emergency care providers.Emergency Contact InfoIn case of emergency, please contact our officeat 831-338-2128 during business hours. If itis during non-business hours, please call ouroffice at 831-338-2128, EXT 1408.Page 4

Diabetes ManagementDietary Management – All food service willbe approved and supervised by a RegisteredDietician. Along with the RD, there will be ateam of interns assisting with all meals. Foodmay be adjusted to better suit your child’sdaily activities while at camp, so please DONOT send food to camp. Food sent fromhome will make it harder for the medical staffto properly monitor your child’s diabetes.However, if your child has specific dietaryrestrictions (e.g. celiacs or nut allergies)you may provide certain food items with theunderstanding that these will be kept in thekitchen and only accessed by the staff.Diabetes Management – Camp will providethe majority of the medical supplies, suchas insulin, syringes, meters and test strips.We will have pump supplies on hand as well.However, to ensure your child has the exactset they prefer, you may pack extras for theweek. We ask that if you do so, please putthe supplies in a large plastic bag with yourchild’s name on it. Any unused supplies willbe returned at the end of camp. All medicalinformation will be verified before the startof camp. Campers will be under the careof a Pediatric Endocrinologist and severalRegistered Nurses. Due to the energetic natureof camp, the doctors may make changes toyour child’s diabetes regimen. At the end ofcamp you will be given a copy of your child’sweekly medical log. For families droppingoff and picking up their child at YMCA CampCampbell, you may also have an opportunity tospeak with the medical staff.Behavior at CampAttending Y camp is a privilege that you as aparent/guardian have chosen for your child.Our staff will make every attempt to providepositive, realistic expectations and guidelinesfor your children. All campers, prior toadmission to camp, must sign the memo ofunderstanding (on the back of the HealthHistory Form), which signifies that they bothunderstand and agree to abide by the camprules. For many children this is the first timethat they have signed a formal agreement andis a good opportunity for you and your child todiscuss the positive nature of good behaviornot only at camp but also in other aspects ofhis or her life.Campers who cannot follow the camp rules orare adversely affecting the experience of othercampers will be dismissed without a refund. Inthese instances, it is the responsibility of theparent or guardian to pick up their child fromcamp immediately.Summer Payment and Refund InformationDeposit: A deposit of $100 must accompanyyour registration and is applied to the totalcamp fee. Deposits are not refundable underany circumstances. In case of homesickness,dismissal for behavior or voluntary withdrawal,there is no refund of any fees. We willrefund program fees, minus the deposit, forcancellations made at least 30 days prior to thestart of camp.Page 5

InsuranceParents/guardians are responsible for anymedical costs incurred as a result of injury orillness while your child is at camp. Be sure toprovide accurate health insurance information(carrier and policy number) on the healthhistory form.Licensing and AccreditationOur camps are inspected annually by theCounty Health Department. Additionally,we are accredited by the American CampAssociation, meeting the highest standardsin nearly 300 areas, including health, safety,personnel, transportation and facilities.Quick Reference Phone NumbersRegistration Questions 408-351-6465and/or Bus Confirmation (M-F, 9 am-3 pm)Camp Questions 831-338-2128(program, health form, waiver, etc.)After-hoursEmergencies831-338-2128 x1408During Summer or 831-278-1617Page 6

Summer Camp Preparation Listo Please send the Medical Approval Form to your provider or call and askthem to complete it. Your provider may already have a blank version ofthis form.Lucile Packard patients: Barry Conrad at barconrad@lpch.org or650-498-7353Oakland Children’s patients: Lois Carelli at LCarelli@mail.cho.orgKaiser patients: call diabetes educator OR log on to www.kp.org, emaildiabetes educator (you may need to link to a family member)UCSF: diabetes educator lineo Complete all required forms immediately.m Health History Form with current immunization history/doctorsignaturem Liability Waiverm Climbing Tower and High Ropes Waiverm Pick up authorization pagem Additional waivers required for Specialty Camps (these will bemailed separately to you, if needed)o Prepare camper for time at camp; discuss behavior expectations.o Mark all packed clothing and equipment with your child’s name.o Bring medications separately (in original container and following theguidelines outlined under the “Medications” section of this guide) – notpacked with your child’s belongings.Page 7

YMCA OF SILICON VALLEY | Resident/Travel Camp Health History Form(Complete one form per child - ALL pages - Must be submitted immediately)Fax or email to: YMCA Camp Campbell at 831-338-9486 or redwoods@ymcasv.orgChild’s Name: ______________________________________________________________ o M o F Age (during camp)_______ Birthdate _____ /_____ /_____Address: ____________________________________________________________ Apt.#________ City___________________________ Zip___________________ Grade _________Parent/Guardian 1: ______________________________________________________ Parent/Guardian 2: _______________________________________________________Home Phone #: ____________________________________________________________ Home Phone #: ____________________________________________________________Employed by: ______________________________________________________________ Employed by: ______________________________________________________________Occupation: _______________________________________________________________ Occupation: ________________________________________________________________Business Phone: _________________________________________________________ Business Phone: __________________________________________________________EMERGENCY INFORMATIONName: _____________________________________________________________________________________ Phone: _____________________________________ Relationship: _________________________________Name: _____________________________________________________________________________________ Phone: _____________________________________ Relationship: _________________________________Name: _____________________________________________________________________________________ Phone: _____________________________________ Relationship: _________________________________INFO REQUIRED BY STATE LAWIf you have insuranceHealth Insurance Co.: __________________________________________________________________Policy Number: __________________________________________________________________________Family Physician: ________________________________________________________________________Phone: _____________________________________________________________________________________Family Dentist: __________________________________________________________________________Phone: _____________________________________________________________________________________DPT: _____________________________________Tetanus: ________________________________Oral Polio: _______________________________Medical Information past or present (please check)Allergies & SPECIAL NEEDS (please check)Measles: ______________________________Mumps: _______________________________Rubella: _______________________________Asthmao Yes o No ADD/ADHDo Yes o No Measleso Yes o NoHeart Defect/Disease o Yes o No Head Lice (recent) o Yes o No German Measles o Yes o NoRecent Hospitalization o Yes o No Bed-wettingo Yes o No Psychological Conditions o Yes o NoCurrently under Dr. care o Yes o No Sleepwalkingo Yes o No Celiac disease o Yes o NoSeizureso Yes o No Tuberculosiso Yes o No Migraineo Yes o NoDiabeteso Yes o No Chicken Poxo Yes o No Other Conditions o Yes o NoFor each Yes, please explain: ______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Hay Fevero Yes o No Bee Stingso Yes oNo Penicillino Yes o NoOak/Ivy Poisoning o Yes o Noo Bee Sting Kit? Other Drugso Yes o NoFoodso Yes o No Other insects or animals o Yes o No Any other allergies? o Yes o NoCurrent Medications to be continued at camp (dosage/frequency): _____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Dietary Restrictions? : o Yes o No ____________________________________________________________________________________________________________________________Any reason to restrict full activity including swimming, long hikes, strenuous physical games?: o Yes o NoIf Yes, please explain: ___________________________________________________________________________________________________________________________________________________Non-prescription medications I authorize the following medications to be administered as needed:Tylenol o Yes o No Benadryl o Yes o NoChloraseptic o Yes o No Cough Drops o Yes o NoClaritan/loratedine/antihistamine o Yes o NoPepto BismolIbuprofenVACCINES (APPROX DATE IMMUNIZED)o Yes o Noo Yes o NoNeosporinCalamine Lotiono Yes o Noo Yes o NoCamper's Name: Last_____________________________________________________ First______________________________ Session: ______________________

Camper’s Name: Last First Session:Specific Diabetes Medical QuestionsOnset of Type 1 Diabetes: Age YearInsulin Brand: Lilly Novo-Nordisk AventisInsulin Type: Humalog Novolog Apidra Lantus Regular NPHIf other, please specify:What is the total daily dose of insulin for one average day? (Lantus, NPH, Humalong/Novolog), (Basal/Bolus combined)Breakfast Dosage: units Lunch Dosage: units Dinner Dosage: units Bedtime Dosage: unitsWhen do you normally give the insulin? Before your child eats After your child eatsHow much does your child weigh? lbs ozDoes camper wear pump? Yes No If so, how long has your camper worn their pump?Pump make:Pump model:Who changes the pump sites?How often is the pump site changed?Do you give your permission to allow a pump site insertion should your child want to experience wearing one? Yes NoWhat type of infusion set is used?Basal Rate (time/rate): Basal Rate (time/rate): Basal Rate (time/rate):Basal Rate (time/rate): Basal Rate (time/rate): Basal Rate (time/rate):Does camper use an insulin pen? Yes No If yes, what type(s)?Is camper on a sliding scale? Yes No If so, how much?Does camper recognize low blood sugar? Yes No SometimesPlease list camper’s usual signs of low blood sugar:How often does this occur?What time in the day does this typically occur?Does camper have a history of seizures? Yes No Frequency of seizures?Please enter the Meal/Cho Bolus ratio–ratios of insulin to carbohydrate grams in units (e.g. number of units of insulin to grams ofcarbohydrates).At what level do you correct your camper’s blood sugar (e.g. – at 180 mg/dl)?How much does one unit of Humalog/Novolog/Regular insulin drop your camper’s blood sugar?Does your camper have issues with bedwetting? Yes No Sometimes If so, how often does it occur?Has your camper been away from home before? Yes NoIf so, for how long and who managed their diabetes while they were away?Has your camper ever been at a residential Type 1 Diabetes camp before? Yes NoIf so, which camp?How does you camper feel about attending camp?

Camper’s Name: Last First Session:Diet QuestionsPlease select one of the following: Camper uses the exchange system Camper counts carbohydrates Camper does not follow any diet/food planadditional questions about camperWhat do you hope your camper will gain from this experience?My camper would like to share a cabin with .We do our best to honor requests, however, we cannot guarantee this request will be fulfilled. Campers are generally assigned tocabins according to gender, age, and grade in the fall.Notes for StaffPlease provide any other information, suggestions, or disciplinary ideas that will help the staff provide your camper with a positiveexperience.

Camper’s personal physician name:Address:City/State:Medical Approval FormPhone:Zip Code:MEDICAL CONSENT TO PHYSICIAN: Permission is hereby granted to release medical information to the YMCA of Silicon Valley fortheir camp programs:Camper’s name (print): Age: Sex: M F Height: Weight:Camper’s parent/guardian signature:Date:PHYSICIAN’S STATEMENT (must be completed by physician within 6 months prior to camp):It is my understanding that the parent or guardian will provide accurate information regarding the correct insulin, insulin deliverymethod, and daily dosage requirements of the aforementioned camper with diabetes.MOST RECENT GLYCOHEMOGLOBIN (HbA1c):Date: Results: Lab Norms: Test not done Are there any particulars about the patient’s diabetes that should be known?History of seizures with hypoglycemia? No Yes, please explain:Has camper been hospitalized within the last twelve months? No Yes, please explain:Other medical conditions that should be known–physical, emotional/behavioral, or special considerations during menses:Medications-list time of day, dosage and reason camper takes other medications (other than insulin):Allergies to: Drugs Food Insects OtherAre there any dietary restrictions?At this time, to my knowledge, he/she does not have any communicable disease: Yes/True No/FalseIn my opinion, he/she is in adequate physical condition and diabetic control to function at camp. Yes No, please explain:Physician’s SignatureDateFax or email forms to:Stamp or print:YMCA Camp CampbellPhysician’s name:831 338 9486 Address:redwoods@ymcasv.orgPhone:*If applicable, please include a photocopy of insurance card.Camper's Name: Last_____________________________________________________ First______________________________ Session: ______________________

YMCA OF SILICON VALLEYRELEASE AND WAIVER OF LIABILITY AND INDEMNITY AGREEMENTIN CONSIDERATION of being permitted to utilize the facilities, services and programs of the YMCA (or formy children to so participate) for any purpose, including, but not limited to observation or use of facilitiesor equipment, or participation in any off-site program affiliated with the YMCA, the undersigned, for himselfor herself and such participating children and any personal representatives, heirs, and next of kin, herebyacknowledges, agrees and represents that he or she has, or immediately upon entering or participating will,inspect and carefully consider such premises and facilities or the affiliated program. It is further warranted thatsuch entry into the YMCA for observation or use of any facilities or equipment or participation in such affiliatedprogram constitutes an acknowledgment that such premises and all facilities and equipment thereon and suchaffiliated program have been inspected and carefully considered and that the undersigned finds and acceptssame as being safe and reasonably suited for the purpose of such observation, use or participation by theundersigned and such children.IN FURTHER CONSIDERATION OF BEING PERMITTED TO ENTER THE YMCA FOR ANY PURPOSE INCLUDING, BUTNOT LIMITED TO OBSERVATION OR USE OF FACILITIES OR EQUIPMENT, OR PARTICIPATION IN ANY OFF-SITEPROGRAM AFFILIATED WITH THE YMCA, THE UNDERSIGNED HEREBY AGREES TO THE FOLLOWING:1. THE UNDERSIGNED, ON HIS OR HER BEHALF AND BEHALF OF SUCH CHILDREN, HEREBY RELEASES, WAIVES,DISCHARGES AND CONVENANTS NOT TO SUE the YMCA, its directors, officers, employees, and agents(hereinafter referred to as “releases”) from all liability to the undersigned or such children and all his personalrepresentatives, assigns, heirs, and next of kin for any loss or damage, and any claim or demands therefore onaccount of injury to the person or property or resulting in death of the undersigned, whether caused by thenegligence of the releases or otherwise while the undersigned or such children is in, upon, or about the premisesor 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 releases and eachof them from any loss, liability, damage or cost they may incur due to the presence of the undersigned or suchchildren in, upon or about the YMCA premises or in any way observing or using any facilities or equipment of theYMCA or participating in any program affiliated with the YMCA whether caused by the negligence of the releasesor otherwise.3. THE UNDERSIGNED HEREBY ASSUMES FULL RESPONSIBILITY FOR AND RISK OF BODILY INJURY, DEATH ORPROPERTY DAMAGE to the undersigned or such children due to negligence of releases or otherwise while in,about or upon the premises of the YMCA and/or while using the premises or any facilities or equipment thereonor participating in any program affiliated with the YMCA.THE UNDERSIGNED further expressly agrees that the foregoing RELEASE, WAIVER AND INDEMNITYAGREEMENT is intended to be as broad and inclusive as is permitted by the law of the State of California andthat if any portion thereof is held invalid, it is agreed that the balance shall, notwithstanding, continue in fulllegal force and effect.THE UNDERSIGNED HAS READ AND VOLUNTARILY SIGNS THE RELEASE AND WAIVER OF LIABILITY ANDINDEMNITY AGREEMENT, and further agrees that no oral representations, statements or inducement apart fromthe foregoing written agreement have been made.I HAVE READ THIS RELEASE.__________________________________________________________ __________________________________________________________Signature of Applicant/Parent Date Print Name of Child in Program Date__________________________________________________________ __________________________________________________________Print Name of Applicant/Parent Date Print Name of Child in Program Date__________________________________________________________ __________________________________________________________Signature of Applicant/Parent Date Print Name of Child in Program Date__________________________________________________________ __________________________________________________________Print Name of Applicant/Parent Date Print Name of Child in Program Date

YMCA Camp Campbell - Climbing Tower and High Ropes Challenge CourseRelease of Liability & Assumption of Risk AgreementNOTICE: THIS IS A LEAGALLY BINDING AGREEMENT. YMCA Camp Campbell’s Climbing Tower and High Ropes Course programs includes a climbingtower, high ropes challenge course and low elements activities. The activities on the tower and ropes course are strenuous and psychologicallydemanding and require participants to be in good physical condition. Although it is impossible to foresee all possible dangers, some specific risksthe participant may encounter while using the tower or ropes course might include, but are not limited to, injury from slipping, falling, running, orjumping.• Participant is aware and understands that participating in YMCA Camp Campbell’s Climbing Tower and High Ropes Course Program involvesa potential risk of physical injury that may not only be from his/her own actions, inactions, or negligence, but also from the actions,inactions, or negligence of others, the condition of the environment, equipment, or areas where the event or activity is being conducted.• Participant understands that the programs are physically demanding and potentially dangerous. Therefore, all participants must be freeof medical or physical conditions, which might create undue risk to themselves or others who depend on them. If there are any questionsabout the participant’s ability to participate, please consult with the participant’s physician prior to signing this form or participating in theprogram.• Participant understands that he/she is responsible for behaving in a careful and prudent manner to minimize the risk of injury tothemselves or others.• Participant understands that this is a voluntary program and that he/she should participate to the extent that they feel appropriate fortheir own condition and skill level.• Participant will not be able to participate if under the influence of drugs or alcohol.Release/Indemnification and Covenant Not to SueIn consideration of my use of the Climbing Tower and High Ropes Challenge Course, I, ________________________________________, the undersigned user, agree torelease and on behalf of myself, my heirs, representatives, executors, administrators, and assigns, HEREBY DO RELEASE the YMCA Camp Campbell,its officers, agents, and employees from any cause of action, claim, or demand of any nature whatsoever, including but not limited to, a claim ofNEGLIGENCE, which I, my heirs, representatives, executors, administrators and assigns may now have, or have in the future against the YMCA CampCampbell on account of personal injury, property damage, death or accident of any kind, arising out of or in any way related to my use of the ClimbingTower or High Ropes Course whether that use is supervised or unsupervised, however the injury or damage is caused, including, but not limited to theNEGLIGENCE of the YMCA Camp Campbell, its officers, agents, and employees.In consideration of my use of the Climbing Tower and High Ropes Course, I, the undersigned user, agree to INDEMNIFY AND HOLD HARMLESS theYMCA Camp Campbell, its officers, agents, and employees from any and all causes of action, claims, demands, losses, or costs of any nature whateverarising out of or in any way related to my use of the Climbing Tower and Ropes Course.I hereby certify that I have full knowledge of the nature and extent of the risks inherent in the use of the Climbing Tower and High Ropes Course andthat I am voluntarily assuming the risks. I understand that I will be solely responsible for any loss or damage, including death, I sustain while usingthe Climbing Tower and High Ropes Course and that by this agreement the YMCA Camp Campbell of any and all liability for such loss, damage, ordeath.I further certify that I am in good health and that I have no physical limitations which would preclude my safe use of the Climbing Tower and HighRopes Course.I further certify that my date of birth is _____________ (month/date/year), that my present age is ______, and that I am therefore of lawful age (18 years orolder) and otherwise legally competent to sign this agreement. I further understand that the terms of this agreement are legally binding and certifythat I am signing this agreement, after have carefully read it, of my own free will.I have read this release of liability and acknowledge and agree to be bound by the terms of this document.Printed NameSignatureAddressDateHome Phone # Emergency Phone #If the participant is under the age of 18, the parents or legal guardian’s signature is required.Child’s NameSignature of Parent/Legal GuardianDate

Pick- Up Authorization(To be completed by parent/guardian)At the YMCA, we take our responsibility for the well-being of your child very seriously. If you (the legal parent/guardian) do not pick up your child on Closing Day, we want to make sure the person who does pick up yourchild has your authorization.Camper’s Name:__________________________________________________________________ Session Date:________________________________________I, ________________________________________________________________(printed parent/guardian name), give permission for my childto be released from camp to the following adults:Name as it appears on driver’s license Relationship Phone Number______________________________________________________ ___________________________________ _____________________________________________________________________________________________________ ___________________________________ _____________________________________________________________________________________________________ ___________________________________ _____________________________________________________________________________________________________ ___________________________________ _______________________________________________Parent/guardian signature:____________________________________________________________ Date:___________________________________________For Camp Use Only on Closing DayI am picking up the above named child from YMCA Camp Campbell and assuming fullresponsibility for him/her.Name:________________________________________________Signature:_______________________________________Released by (cabin leader):__________________________________________________________________________Authorized before leaving camp property by:_________________________________________________