Rotary youth leadership awards camp health information & consent for emergency treatment

ROTARY YOUTH LEADERSHIP AWARDS CAMP

HEALTH INFORMATION & CONSENT FOR EMERGENCY TREATMENT

This information on this form will be kept confidential and will only be used by medical personnel.
Student’s Last Name First DOB Sex

Street Address City Zip Insurance Company Policy Number In case of emergency notify Phone Relationship to Participant: Parent Guardian: Other (specify) Family Physician or Clinic Phone Date of Last Tetanus Shot

Please answer the following questions, and explain each “YES” response below:

Yes No

1. 
   Respiratory problems (asthma, persistent cough, TB, etc.).
   
2. 
   Heart disease (high blood pressure, heart murmur, chest pain etc.).
   
3. 
   Stomach or intestinal problems (ulcers, jaundice, hernia, etc.).
   
4. 
   Kidney, gall bladder or liver disease.
   
5. 
   Diabetes or Hypoglycemia (low blood sugar).
   
6. 
   Muscular/skeletal problems (arthritis, hernia, recent fracture, etc.).
   
7. 
   Eye, ear, nose or throat problems (hay fever, impaired sight or hearing).
   
8. 
   Nervous disorders (convulsions, epilepsy, dizziness, etc.).
   
9. 
   Skin diseases.
   
10. 
    Emotional or mental disorders (frequent anxiety, excessive fear, etc.).
    
11. 
    Surgical Operations, Accidents, Injuries in last 3 years.
    
12. 
    Recent exposure to contagious disease.
    
13. 
    Allergies.
    

14. 
    Are you currently under a doctor’s care?
    
15. 
    Are you currently taking any medication? List below.
    
16. 
    Do you have any special dietary needs?
    
17. 
    Do you have any limiting physical or emotional conditions? Explanations (Use reverse side if necessary)
    

I am of the opinion that my child can and may participate in the Rotary Youth Leadership Awards Camp (RYLA) to be held on the dates listed on the Application form. I further declare that he/she has no physical, emotional, mental or communicable conditions that will interfere with participation in this program. I hereby release Rotary District 5000, Oahu Rotary clubs and all program staff from all liability, including payment for treatment for illness or accidents which may occur.
If a medical emergency arises while my child is participating in the RYLA program, I give my permission for medical personnel to perform whatever health service or treatment is necessary for our child’s health.
Parent/Guardian Signature Print Name
Date Phone number(s)

ROTARY YOUTH LEADERSHIP AWARDS CAMP

Oahu Camp RYLA – November 24-26, 2017 Pokai Bay Applicant Information/Parental Release Form
Please complete this form legibly and in black or dark blue ink.
Name Nickname Age Sex
Mailing Address: City Zip
Home Phone: School Grade
Cell Phone E-Mail Unisex T Shirt Size
Are you an Interact Club member? Instagram Name
Name of Person* who gave you this form/Affiliation:
List your school and/or community activities (Include any elected or leadership positions) + HOBBIES:

PARENT(S)/ GUARDIAN(S) ACCEPTANCE

Our son/daughter has discussed the Rotary Youth Leadership Awards (RYLA) camp with me (us) and I (we) give my (our) permission to apply for participation in this co-ed overnight RYLA program to be held on the dates checked above. Further I (we) give my (our) approval to seek medical assistance should an emergency occur. It is understood that the program is conducted and supervised by Rotary Club from D5000. I (we) further understand that my (our) child is expected to attend the full program and he/she will be transported to and from the camp in the busses provided. I (we) grant permission for the use of camp photographs of my (our) son/daughter by Rotary for RYLA publicity purposes. I hereby release Rotary District 5000, OAHU Rotary clubs and all program staff from all liability, including payment for treatment for illness or accidents which may occur.
Signature of Parent/Guardian Print Name
Emergency Phone Numbers: Cell Phone Other
Signature of Parent/Guardian PrintName
Emergency Phone Numbers: Cell Phone Other
RETURN THE COMPLETED 3-PAGE APPLICATION TO Rock Arakaki.

SCAN AND EMAIL TO: [e-mail] or take a photo of each page and text to 255-8669
Hawaiian Canoe Racing Association Insurance Program Canoe Club: Adult and Minor Waiver and Release of Liability January 1, 2017 to December 31, 2017

In consideration of being allowed to participate in any way in the Hawaiian Canoe Racing Association and its member organizations’ athletics/sports programs, and related events and activities, the undersigned:

1. 
   Agree that prior to participating, they each will inspect the facilities and equipment to be used, and if they believe anything is unsafe, they will immediately advise their coach or supervisor of such condition(s) and refuse to participate.
   

2. 
   Acknowledge and fully understand that each participant will be engaging in activities that involve risk of serious injury, including permanent disability and death, and severe social and economic losses which might result not only from their own actions, inactions or negligence, but the action, inaction or negligence of others, the rules of play, or the condition of the premises or of any equipment used. Further, that there may be other risks not known to us or not reasonably foreseeable at this time.
   

3. 
   Assume all the foregoing risks and accept personal responsibility for the damages following such injury, permanent disability or death.
   

4. 
   Release, waive, discharge and covenant not to sue the Hawaiian Canoe Racing Association, its member associations, its affiliated clubs, their respective administrators, directors, agents, coaches, and other volunteers or employees of the organization, other participants, sponsoring agencies, sponsors, advertisers, and if applicable, owners and leasers of premises used to conduct the event, all of which are hereinafter referred to as “releasees”, from demands, losses or damages on account of injury, including death or damage to property, caused or alleged to be caused in whole or in part by the negligence of the releasee or otherwise.
   

The undersigned custodial parent or legal guardian acknowledges that he/she is also signing this release on behalf of the minor participant, that he/she is waiving certain rights on behalf of the minor participant that the minor participant otherwise may have and that the minor participant shall be bound by all of the terms of this release. By signing this waiver and release without a parent’s or guardian’s signature, the participant represents he/she is at least 18 years of age, or, if signing as the parent or guardian of the participant, signer represents they are the custodial parent or legal guardian of the minor participant.

THE UNDERSIGNED HAVING READ THE ABOVE WAIVER AND RELEASE, UNDERSTAND THAT THEY HAVE GIVEN UP SUBSTANTIAL RIGHTS BY SIGNING IT AND SIGN IT VOLUNTARILY.
Paddler Name (print) _ Sex □ F □ M Street Address Birthdate City State Zip Code Phones: Home Work Cell/Pager Email Address In an emergency, contact Phone
If a minor, Printed Name of Custodial Parent or Guardian
Signature: Date

(Adult Paddler or Minor’s Guardian)

CODE OF CONDUCT
2017-18 RYLA PROGRAM - D5000 ROTARY CLUBS

THE RYLA PROGRAM STAFF WISHES TO PROVIDE A SAFE, SECURE SETTING FOR ALL THOSE WHO PARTICIPATE IN THIS PROGRAM.

The following Code of Conduct rules and conditions will apply to all RYLA participants, staff and visitors throughout the Camp RYLA program checked on the Application form.

• 
  Possession or use of alcoholic beverages or illegal drugs is prohibited.
  
• 
  Smoking or any use of tobacco products is prohibited.
  
• 
  Participants are responsible for keeping sleeping area and room clean and orderly
  
• 
  Sleeping arrangements will be assigned and are same-sex to a room. Assignments are made by staff in an effort to maximize your opportunity to make new friends. Changing of room assignments is not permitted without prior approval by the program staff.
  
• 
  Participants must attend all program events at specified times, unless excused by program staff.
  
• 
  Appropriate clothing is to be worn at all times.
  
• 
  All program participants must respect personal, camp and public property. Repair costs for damages incurred to property will be billed to the responsible party.
  
• 
  Participants are not to have an automobile available to them during the program. Transportation will be provided to and from the camp.
  
• 
  Participants are expected to abide by curfews and to be in their assigned rooms at times as designated by the staff.
  
• 
  The use of cell phones will not be permitted during the program except during break periods as designated by the staff. Emergency incoming calls will be accepted by the Camp Director at this number: Rock Arakaki 808.255-8669
  

Participants are expected to attend the full program, and if, for any reason, you know that you cannot do this, please do not apply for participation. Requests to not take part in any program activity or to leave before the end of the program will only be considered by the program staff for an exceptional basis, i.e., family emergency, injury, illness, physical limitation, etc. If it becomes necessary for you to leave the program because of such circumstances, your parents will be notified and they will be responsible for arranging all transportation from the camp to your home. Only parents or guardians may give such permission to leave the program and to provide transportation. Any participant who leaves the program early will not be permitted to return, and will not receive a Certificate.

Participants who violate this Code of Conduct may be asked by the program staff to leave the camp, in which case the parents will be responsible for picking them up at the camp site and transporting them home as soon as requested.
I have read and agree to conform to the above code of conduct, conditions and exceptions.
Signed (RYLA Participant) Date
Print Name
Signed (Parent/Guardian) Date
Print Name
Phone numbers (Cell, Home, Work)