Dryades YMCA Basketball Summer Camp
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Email *
Camper's Name (First and Last Name) *
Age *
Address (City, State, and Zip) *
Date of Birth (D.O.B) *
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DD
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Sex *
Race *
Ethnicity *
Parent/Guardian's First, Last Name *
Parent/Guardian's Address *
City, State, and Zip *
Parent/Guardian's Phone Number *
Emergency Contact Name *
Emergency Contact Phone Number *
Relationship to Camper *
Required
Please list the individuals allowed to pick-up your child.  Be sure to give an undated contact information for each person listed below (Photo ID will be required) *
How will your child be leaving camp? *
Please list any Allergies your child may have. *
Does your child use an EPI PEN *
T-Shirt *
His the camper ever been treated for attention deficit disorder (ADD) or attention deficit/hyperactivity disorder(ADHD) *
During the past 12 months his the camper seen a professional to address mental/emotional health concerns? *
Is there any other information we need to know about your child? *
Camp Waivers and Releases
This next questions contain a series of policies and releases. Please read carefully and acknowledge with your
initials next to each item.
Consent for Health Care I authorize the Dryades YMCA, its staff and /or employees to engage such professional medical care or hospital laboratory services as may appear to be necessary or desirable for the protection of the health or life of my minor child named above. Any person rendering health care pursuant to this authorization shall be entitled to treat with consent given by the undersigned. I agree to be responsible for any charges incurred in the rendition of such care and treatment. *
Field Trip I give my child permission to participate in all field trips during summer camp. I understand that proper supervision will be provided. Transportation to these field trips will be contracted by the Dryades YMCA an their partners. *
Swim Release I give my child permission to participate in all swim sessions during summer camp. I understand that proper supervision will be provided by the Dryades YMCA *
Consent for Emergency Treatment In the event of an emergency, permission is given to a physician, selected by the Dryades YMCA Staff, to administer whatever medical treatment deemed necessary as a result of an accident or illness which may occur. *
Coronavirus/COVID-19. By signing this agreement, I acknowledge the contagious nature of COVID19 and voluntarily assume the risk that my child(ren) and I may be exposed to or infected byCOVID19 by my child(ren) attending the Program and that such exposure or infection may result in personal injury, illness, permanent disability, and death. I understand that the risk of becoming exposed to or infected by COVID-19 at the Site may result from the actions, omissions, or negligence of myself and others, including, but not limited to, the Dryades YMCA and their employees, volunteers, and program participants and their families. I  voluntarily agree to assume all of the foregoing risks and accept sole responsibility for any injury to my child(ren) or myself (including, but not limited to, personal injury, disability, and death), illness, damage, loss, claim, liability, or expense, of any kind, that I or my child(ren) may experience or incur in connection with my child(ren)’s attendance or participation in the Program (“Claims”). On my behalf, and on behalf of my children, I hereby release, covenant not to sue, discharge, and hold harmless the City, Dryades YMCA, their employees, agents, and representatives, of and from the Claims, including all liabilities, claims, actions, damages, costs or expenses of any kind arising out of or relating thereto. I understand and agree that this release includes any Claims based on the actions, omissions, or negligence of the City and/or Dryades YMCA, their employees, agents, and representatives, whether a COVID-19 infection occurs before, during, or after participation in any Program. In addition, the undersigned acknowledges that COVID-19 infections have been confirmed through out the United States, with over 6,000 confirmed cases in New Orleans alone. In accordance with the most recent guidance and protocols issued by WHO, the Centers for Disease Control and Prevention(“CDC”), and the Louisiana Department of Health, for slowing the transmission of COVID-19, the undersigned hereby agrees, represents, and warrants that neither the undersigned nor such participating children shall visit or utilize Sites, services, or Program within fourteen (14) days after exposure to any person who has a suspected or confirmed case of COVID-19. Furthermore, the undersigned here by agrees, represents, and warrants that neither the undersigned nor such participating children shall visit the Sites or attend the Program if he or she (i) experiences symptoms of COVID-19, including, without limitation, fever, cough or shortness of breath, or (ii) has a suspected or diagnosed/confirmed case ofCOVID-19. The undersigned agrees to notify the Dryades YMCA immediately if he or she believes that any of the foregoing access/use restrictions may apply. *
Release of Liability Please read this form carefully and be aware that for participation in the program(s), you will be waiving and releasing all claims for injuries you or your child (children) might sustain arising out of the program(s). I recognize and acknowledge that there are certain risks of physical injury to participants in the program(s) and I agree to assume the full risk of any such injuries, damages, or loss regardless of severity which I or my child (children) may sustain as a result of participating in any of the program(s). I hereby fully release and discharge the City of New Orleans, Dryades YMCA and its officers, agents, servants and employees from any and all claims resulting from injuries, damages and losses sustained by me or my child (children), and arising out, connected with, or in any way associated with activities of any of the programs. *
A copy of your responses will be emailed to the address you provided.
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