The Watersports Camp

Campership Registration Form

Child’s Name (Last, First, Middle Initial) _____________________________________________________________________________

Child’s Birthdate______________________________________________________________________ Age ______________________

Parents’s Name (Last, First) ______________________________________________________________________________________

Address _____________________________________________________________________________________________________

City/State/Zip _________________________________________________________________________________________________

Day Phone ___________________________________________Evening Phone ___________________________________________

Please do not send me information
E-mail Address (required) _________________________________________________________________ about special discounts or offers.

2011 Schedule (Please enter the week number next to the camp you will be attending)
Organization Name: Please select your Morning Instructional
Armed Services - YMCA Activity:
Basic Sailing
Spring Sessions Summer Sessions
Advanced Sailing
Week Dates Week Dates
SP1 April 4-8 1 June 6-10 Hobie Cat Sailing
SP2 April 11-15 2 June 13-17 Kayaking
SP3 April 18-22 3 June 20-24 Wakeboarding & Waterskiing
4 June 27-July 1 Windsurfing

Please be sure to bring the following items

CAMP SCHEDULE to camp each day:
7:30am-8:00am - sunscreen (VERY VERY IMPORTANT!!)
Camp Drop Off - a lock to lock your stuff up in the bathroom
8:00am-11:00am lockers (VERY IMPORTANT!)
Morning Instructional - swimsuit
- towel
Activity
11:00am-11:30am - change of clothes and footwear
- sweatshirt or windbreaker for chilly mornings
Lunch - footwear (sandals, flip flops, etc)
11:30am-3:00pm
- lunch – except on Fridays because we provide a
Afternooon Activity picnic lunch for parents and campers!
3:00pm-4:00pm - back pack large enough to hold the above items
Camp Pick-up
PLEASE RETURN OR FAX THIS COMPLETED PACKET TO (858)
488-9625 NO LATER THAN THE WEDNESDAY PRIOR TO THE
START OF YOUR CAMP!
MEDICAL HISTORY/CHECK-OUT PERMISSION FORM
CHILD’S NAME__________________________________________________
BIRTHDATE___________________________ AGE__________________
FATHER’S NAME______________________DAY PHONE(___)_____________
EVENING PHONE(____)______________CELL PHONE(____)______________
ADDRESS_____________________________________________________
CITY_______________________ STATE________ ZIP______________
MOTHER’S NAME______________________DAY PHONE(___)_____________
EVENING PHONE(____)______________CELL PHONE(____)______________
ADDRESS_____________________________________________________
CITY_______________________ STATE________ ZIP_______________

IN CASE OF EMERGENCY-NOTIFY
*Please list two emergency contacts other than parents
NAME DAY PHONE EVENING PHONE

_________________________________________________________
_________________________________________________________
FAMILY PHYSICIAN

_________________________________PHONE(____)______________
Please list any conditions that currently require regular medication (If you will be requiring us to
administer medication you must sign the Authorization to Administer Medication form at camp
check-in):
_________________________________________________________
Does your child have any physical or developmental limitations with regard to these activities
that might require special attention for your child’s safety during participation?
______________________________________________________________

______________________________________________________________
(please use the back of this page if necessary)

* CAMP CHECK-OUT * In the Last 7 Days has your camper:

In order to ensure the safety of all campers, we 1. Had a fever of over 100 degrees? … yes … no
will be checking the identification of any
parent/sibling/friend/carpool driver that will be 2. Had a sore throat? … yes … no
picking up campers. ONLY INDIVIDUALS 3. Had a cough? … yes … no
LISTED ON THIS FORM WILL BE ALLOWED
TO PICK UP A CHILD. Photo identification is If you checked “yes” for fever AND one or two of the other
REQUIRED (ex. Valid driver’s license). symptoms, keep your child at home because of an influenza-
like illness. Call our office to discuss rescheduling camp, or to
_____________________________ request a full refund. Current recommendation is that children
remain home for seven days after symptoms start, even if the
_____________________________
child is no longer ill. If your child is still sick after seven days,
keep your child at home until well for 24 hours. If you have
questions about your child’s health or symptoms, call your
_____________________________ child’s healthcare provider.
 PENINSULA FAMILY YMCA YOUTH PROGRAMS 8. LEGAL FEES. In the event of any controversy, claim or dispute between the parties arising
RELEASE AGREEMENT out of or relating to this agreement or the breach hereof or the activity, the prevailing party shall
be entitled to recover from the losing party reasonable expenses, attorney fees and costs.
In consideration of the use of the property, facilities and/or services of the Peninsula Family
YMCA Youth Programs, including any travel related thereto, the undersigned agrees as 9. REPRESENTATIVES. The undersigned enters into this agreement for himself/herself,
follows: heirs, assigns and legal representatives.

1. RISK FACTORS. The undersigned understands and acknowledges that the activities of 10. ACKNOWLEDGEMENT. The undersigned has read and understands this agreement and
wakeboarding, waterskiing, surfing, sailing, windsurfing, kayaking, rowing, marine science, realizes it relates to releasing valuable legal rights and does so freely and voluntarily.
related water sports, beach activities, transportation during camp, and transportation before and
after camp by camp personnel involve risks such as but not limited to the following which 11. TOWER ACKNOWLEDGEMENT. For use of Air Nautique wakeboard boats with a
might result from the activity itself, the acts of others or the unavailability of emergency care; tower, I further understand this exposes the above named minor to the additional risks of a large
RISK OF PROPERTY DAMAGE, BODILY INJURY, and POSSIBLY DEATH. wake and the possible serious injuries resulting from aerial or other maneuvers.

2. ASSUMPTION OF RISK. The undersigned ASSUMES ALL RISKS WHICH ARE

FORESEEABLE AND INVOLVED WITH OR ARISING FROM THE ACTIVITY, including ___________________________________________________ __________________
without limitation those risks described in Section 1 above. NAME OF MINOR AGE

3. SKILLS AND TRAINING. The undersigned acknowledges that the below named minor APPROVAL OF PARENT/LEGAL GUARDIAN ON BEHALF OF MINOR
has the skills, qualifications, physical ability and training necessary to complete such activity.
The undersigned agrees that if he or she has any questions as to what skills, qualifications or I am the parent and/or legal guardian of the above-named minor. I have read and
training is necessary to properly participate in the activity, then they shall direct such questions understand the agreement and realize the agreement involves releasing valuable legal
to the Mission Bay Youth Water Sports Camp management. rights of the minor and myself. I agree to be bound by all of the terms of the
agreement. I also give my consent to the participation in the activity by the minor. I
4. RELEASE. The undersigned RELEASES the State of California, Peninsula Family YMCA, also give my consent for my child to be included in photographs, videos, slides, and
the YMCA of San Diego County, the Trustees of the California State Universities, San Diego movies taken at the Center by students, staff, TV, Radio and/or other news media. I
State University, Regents of the University of California, the University of California San understand that pictures become property of Associated Students of SDSU, and might
Diego, the Associated Students of San Diego State University and all of their officers,
employees and agents (referred to below as the “RELEASED PARTIES”) and agrees NOT TO
appear in promotional materials and publications:
SUE them on account of or in connection with any claims, causes of action, injuries, damages,
cost or expenses (referred to below as “CLAIMS”) arising out of the activity, including those
based on the risks described in Section 1, whether or not caused by the negligence or other fault ___________________________________________________ ___________________
of the RELEASED PARTIES. SIGNATURE OF PARENT AND/OR LEGAL GUARDIAN DATE
IF PERSON PARTICIPATING IS UNDER 18
5. WAIVER. The undersigned waives the protection provided by any statute or law in any
jurisdiction including California Code section 1542 whose purpose, substances and/or effect is PARENT OR LEGAL GUARDIAN EMERGENCY TREATMENT CONSENT
to provide them a general release shall not extend to claims, material or otherwise which the
persons giving the release does not know or suspect to exist at the time of executing the release. As the parent and/or legal guardian, I agree to the participation by the minor in the subject
This means, in part, that the undersigned is releasing unknown future claims. activity. The undersigned hereby gives consent to medical treatment of the minor in case of an
emergency.
6. INDEMNIFY AND DEFEND. The undersigned agrees to INDEMNIFY AND DEFEND
the RELEASED PARTIES against, and hold them harmless from, any and all CLAIMS, ___________________________________________________
including attorney fees, which in any way arise from the activity which is the subject of this SIGNATURE OF PARENT AND/OR LEGAL GUARDIAN
agreement and which include but are not limited to those risks described in Section 1 including IF PERSON PARTICIPATING IS UNDER 18
any liability arising from the act or negligent act of the RELEASED PARTIES, the below
named minor or anyone else.
THIS FROM MUST BE RETURNED TO THE MISSION BAY YOUTH PROGRAMS OFFICE BEFORE
7. PAY. The undersigned agrees to pay for any and all damages to any property of the YOUR CHILD CAN PARTICIPATE IN THE YOUTH ACTIVITIES. IF THIS FROM IS NOT ON FILE
IN THE YOUTH PROGRAM OFFICE, YOUR CHILD WILL NOT BE ALLOWED TO PARTICIPATE
RELEASED PARTIES caused by the undersigned whether negligently, willfully or otherwise.
UNTIL THE PARENT OR LEGAL GUARDIAN SIGNS FOR THEM. THIS FORM MAY NOT BE
EDITED OR CHANGED IN ANY WAY. IF YOU HAVE ANY QUESTIONS REGARDING THIS
RELEASE FORM, PLEASE CONTACT THE YOUTH PROGRAM DIRECTOR AT (858) 539-2003.
CAMP POLICY FOR MEDICATION
For the safety of our students, we have a strict policy for the handling of medication at camp. Our
medication policy changes and evolves each season. If your child will be taking medication while at
camp, please be sure to follow the specific procedures listed below. Please note: Students will not be
admitted to camp if these procedures are not followed.

 We ask that students attending camp please take ALL medication and/or vitamins before camp,
unless they MUST be taken during camp hours.
 ALL medication MUST be brought to camp in their ORIGINAL CONTAINERS on your child’s
first day of camp. Please do not take the medication out of the container.
 The original container must identify (in English) the prescribing physician (if a prescription
drug), the name of the medication, the dosage and the frequency of administration.
 Students will be responsible for self administering medication in accordance with the instructions
below. In the case of emergency, or the camper cannot administer the medication themselves, a
camp staff member will assist.
 Students needing injections (insulin, hormones, etc.) will need to self-administer the medication.
Camp staff are not trained in this area.
 All medication information MUST be completely entered in your child’s Health History form.
 It is the responsibility of the Parent/Guardian to pick up any remaining medication at the end of
the week. Any medication and/or vitamins left at camp will be disposed of.

AUTHORIZATION TO ADMINISTER MEDICATION

I HEREBY AUTHORIZE the designated representatives of The Watersports Camp to administer the medication described
below. It is the policy of MBAC to provide the medicine to the camper to self administer in accordance with instructions below.
Should the camper be unable to administer the medication themselves, a staff member will assist in the administration. In
consideration of the administration of this medication in accordance with the directions of my child’s doctor, I hereby release
The Watersports Camp and its agents or representatives or employees from any and all liability for damages resulting from the
administration of this medication to my child. I further agree to hold harmless and indemnify MBYWSC and its agents or
representatives or employees from any costs or expenses associated with any claim brought against them for actions taken
pursuant to this Authorization to Administer Medication and such indemnification to include attorney fees, costs of any litigation
or claim or any damages or out of pocket costs occasioned by The Watersports Camp, its agents or representatives or
employees.

__________________________________________________ _____________________
Child’s Name Date

__________________________________________________ _____________________
Parent/Legal Guardian* Date

__________________________________________________ _____________________
Prescribing Physician Physician Phone

Medication #1: _____________________________________________ Dosage: ____________________

Time taken:________________________________ Reason for taking:____________________________

Medication #2: _____________________________________________ Dosage: ____________________

Time taken:________________________________ Reason for taking:____________________________

 Youth and Community Outreach Department
Release of Liability Form: Adults and Minors
Parent/Guardian Name(s) (print)______________________________________________________________________
Parents Date(s) of Birth (same order)__________________________________________________________________
Minor Children Participating:
Name_______________________________________________Date of Birth_______________Age______Gender___
Name_______________________________________________Date of Birth_______________Age______Gender___
Name_______________________________________________Date of Birth_______________Age______Gender___
Name_______________________________________________Date of Birth_______________Age______Gender___
th nd
Activity or Group____Spring Watersports Camp __________________________Date(s)_April 4 to April 22 _____
Location__________________________Mission Bay Aquatic Center _______________________________________

I, the undersigned parent/person having legal custody/guardianship of the above said minor, give permission for the minor
to participate in the San Diego Armed Services YMCA program described above. I grant full permission for my child
and/or myself to be photographed by the San Diego Armed Services YMCA staff for any legitimate purpose without
payment or compensation. The minor is physically able and mentally prepared to participate in all activities as described
in the announcement for the program. I hereby voluntarily and knowingly assume all risks and dangers inherent and
incidental to the activities of the program. I will not hold the San Diego Armed Service YMCA liable for any injuries
incurred during the program or while my child(ren) is/are in transit to and from the program whether caused by equipment
or the act or omissions of others excepting damage or injury solely caused by the willful misconduct or negligence of the
San Diego Armed Services YMCA, or its employees, volunteers, or agents.

I do hereby authorize the San Diego Armed Services YMCA as agent for the undersigned, to consent with respect to the
minors, to any x-ray examination, anesthetic, medical, dental, or surgical diagnosis or treatment, and hospital care which
is deemed advisable by, and is to be rendered under general or special supervision of, any physician and surgeon
licensed under the provisions of the California Medical Practice Act on the medical staff of any hospital, whether such
diagnosis or treatment is rendered at the office of the physician or at the hospital. I understand that the San Diego Armed
Services YMCA is not responsible for costs incurred for medical care. If I participate in the program, whether as coach,
instructor, aide, spectator, or participant, I presently waive as to the San Diego Armed Services YMCA and staff, officers
and directors thereof, any claim presently known or unknown for damage to property or personal injury whether caused by
equipment or the acts or omissions of others including San Diego Armed Services YMCA personnel.

****Parent/Guardian (Signature)____________________________________Date___________________****
The San Diego Armed Services YMCA is pleased to invite your child to the Spring Watersports Camp. To confirm your
child’s participation, this registration form and a non-refundable ten dollar deposit (cash/or check only) must be submitted
to the Armed Services YMCA at 3293 Santo Rd, San Diego, CA, 92124 by March 16, 2011.

Each non-refundable deposit will be processed upon completion of registration. Should the child fail to attend the
program, the family can be placed on the ASYMCA ineligible service list.

****Parent/Guardian (Signature)____________________________________Date___________________****

OFFICE USE ONLY: COMPLETE UPON REGISTATION

________________________ _____________ ____________

Form of Deposit (Cash/Check) Date Received Date Processed