LIST NAME AND PHONE NUMBER OF ANOTHER PERSON AUTHORIZED TO PICK UP YOUR CHILD:
The answers to these questions will help us to know if your child has any medical problems.
We need this information in case he/she should become ill and we would be unable to
pbma Child Care program and understand the pbma adheres to these rules. I agree to follow the policies of the pbma. I understand that my failure to do so may result in our being discharged from the program. I understand that payment is expected in advance and that there will be a late fee assessment should I neglect to pay on time. I understand that the pbma is mandated by law to report any suspected child abuse or neglect to the appropriate authorities for investigation. I hereby consent to the use of my child’s likeness in photographs, film, videotape or website for use in editorial, illustrated or promotional purposes.
PBMA considers all registrations without regard to race, color, religion, sex, national origin, or the presence of medical condition or
handicap. However, the pbma does reserve the right to refuse admission to any child who may require a level of attention beyond that which the pbma
programs are designed to accommodate or who may require specialized training that may prevent the pbma staff from adequately meeting the needs of the
child. Limited financial assistance is available
1. This registration form is correct to the best of my
knowledge and the child herein described has permission
to engage in all prescribed activities, except noted by me.
In the event I cannot be reached in an emergency, I hereby
give permission to the physician selected by the adult
leader in charge to hospitalize, secure proper anesthesia,
or to order injection of surgery for my child.
2. I understand that the PBMA does not provide health
insurance coverage for participants. I am responsible for
my own coverage.
3. I have read the rules and policies of the Pbma
Child Care Program. I understand the PBMA adheres
to these rules. I agree to follow the policies of the PBMA.
I understand that my failure to do so may result in my
child being discharged from the program. (Your signature
below indicates that you have received the rules and
policies of the program.
4. I understand that PBMA staff and volunteers are not
allowed to baby sit or transport children at any time
outside of the PBMA program. Immediate disciplinary
action will be taken by the PBMA toward staff and
volunteers if a violation is discovered.
5. I understand that payment is expected the week prior to
service and that there will be a late fee assessed should I
neglect to pay on time.
6. I understand that enrolling by child in the PBMA program
that I have committed to the program for the program term
and that I am charged regardless of my child’s participation.
I understand that in order to remove my child from the
PBMA program, I must fill out a PBMA exit form at least
one week prior to my child’s last day of attendance.
7. I understand that I am not to leave my child at the PBMA
or program site unless a PBMA staff or volunteer is there
to receive and supervise my child.
8. I understand that my child will not be allowed to leave the
program with an unauthorized person. Any person authorized
to pick up my child must either be listed with the
PBMA or other arrangements must be made by calling the
PBMA office to inform them of a change.
9. I understand that should a person arrive to pick up my
child who appears to be under the influence of drugs or
alcohol, for the child’s safety, staff may have no recourse
but to contact the police. (Please do not put staff in a
position in which they have to make this judgment call.)
10. I understand that the PBMA is mandated, by state law,
to report any suspected cases of child abuse or neglect to
the appropriate authorities for investigation.
12. I hereby consent to the use of my child’s likeness in
photographs, film or videotape for use in editorial,
illustration or promotional purposes.
13. IThe PBMA considers all registrations without regard to
race, color, religion, sex, national origin and presence of
medical condition or handicap. However, the PBMA does
reserve the right to refuse admission to any child who may
require a level of attention beyond that which PBMA
programs are designed to accommodate or require
specialized training that may prevent PBMA staff from
adequately meeting the needs of the child.
14. My child’s health history and shot record is current and on
file at the school locaton listed on theregistration form.
15. I give permission to the PBMA to transport my child to
and from field trips, schools, and/or swimming.
16. Limited financial assistance is available.
17. Before any medication is dispensed to my child, I will
provide a written authorization, which includes: name of
my child, date, name of medication, prescription number,
dosage, date of day, and time of day. Medicine will be in
the original container with my child’s name marked on it.
18. My child will not be allowed to enter or leave the facility
without being escorted by the parent(s); person authorized
by parents, or facility personnel.
19. I acknowledge it is my responsibility to keep my child’s
records current to reflect any significant changes as they
occur (i.e. telephone numbers, work location, emergency
contacts, child’s physician, child’s health status, and
20. The PBMA agrees to keep me informed of any incidents,
including illness, injuries, adverse reactions to medications,
exposure to communicable diseases, which include my child.
21. The PBMA agrees to obtain written authorization before
my child participates in transportation, special activities
away from the facility, and water-related activities
occurring in water that is more than two feet deep
Physical exercise, training and related activities can be strenuous and may cause serious injury. PBMA urges every member to obtain a physical examination from a medical doctor before using any exercise equipment or participating in
any exercise or training class, related activity or PBMA sponsored program event or before undergoing changes in diet including the use of foodsupplements, weight reduction and/or body building enhancement products.
I, the undersigned agree to follow all rules and regulations of the Pbma while in, upon or about the premises or while using or observing the premises or any facilities or equipment, and understand and agree that I may be expelled at any time, for failure to abide by such rules and regulations.I, the undersigned, agree to ensure that my child(ren), dependent(s), and/or other minors for whom I am responsible or for whose presence at PBMA. I am responsible follow all rules and regulations of the PBMA while in, upon or about the premises or while using or observing the premises
or any facilities or equipment, and understand and agree that my child(ren), dependent(s) and/or other minors for whom I am responsible or for whose presence at PBMA I am responsible may be expelled at any time, with no refund of any monies paid, for failure to abide by such rules and regulations.
IN FURTHER CONSIDERATION OF BEING PERMITTED TO ENTER THE YMCA FOR ANY PURPOSE INCLUDING, BUT NOT LIMITED TO OBSERVING OR USING ANY FACILITIES OR EQUIPMENT, OR PARTICIPATING IN ANY ON-SITE OR OFF-SITE PROGRAM, ACTIVITY OR CLASS AFFILIATED WITH THE PBMA, INCLUDING USE OF THE PBMA DAY CARE FACILITIES, THE UNDERSIGNED HEREBY AGREE TO THE FOLLOWING:
1. THE UNDERSIGNED, ON HIS OR HER BEHALF AND BEHALF OF HIS OR HER CHILDREN, HEREBY RELEASES, WAIVES, DISCHARGES AND COVENANTS NOT TO SUE the PBMA, its directors, officers, employees, and agents (hereinafter referred to as “releasees”) from all liability to the undersigned or his or her children and all their respective personal representatives, assigns, heirs,and next of kin for any loss or damage, and any claim or demands therefor on account of injury to the person or property or resulting in death of the undersigned or his or her children, whether or not caused by the negligence of any person, the releasees or otherwise while the undersigned or his or her children is in, upon, or about the PBMA premises or any facilities or equipment therein or participating in any program, class or activity affiliated with the PBMA without respect as to location.
2. THE UNDERSIGNED, ON HIS OR HER BEHALF AND BEHALF OF HIS OR HER CHILDREN, HEREBY AGREES TO INDEMNIFY AND SAVE AND HOLD HARMLESS the releasees and each of them from any loss, liability, damage or cost they may incur due to the presence of the undersigned or his or her children in, upon or about the PBMA premises or in any way observing the use of or using any facilities or equipment of PBMA or participating in any program, class or activity affiliated with the PBMA without respect as to location whether or not caused by the negligence of any person, the releasees or otherwise.
3. THE UNDERSIGNED, ON HIS OR HER BEHALF AND BEHALF OF HIS OR HER CHILDREN, HEREBY ASSUMES FULL RESPONSIBILITY FOR AND RISK OF BODILY INJURY, DEATH OR PROPERTY DAMAGE to the undersigned or his or her children whether or not caused by the negligence of any person, the releasees or otherwise while in, about or upon the premises of the PBMA and/or while observing the use of using the premises or any facilities or equipment thereon or participating in any program, class or activity affiliated with the PBMA without respect as to location.
The Undersigned, on his or her behalf and behalf of such children, specifically assumes all risks of personal injury, property loss, or damages whatsoever including risk associated with racquet sports, aerobics, yoga, fitness classes, fitness equipment, exercise, swimming, weights, child care or in any program, class or activity affiliated with PBMA without respect as to location. This assumption of risk also includes environmental, theft, and contagion risks in addition to risk associated with use of the PBMA's health and fitness advisory services.
4. IF THE UNDERSIGNED IS PLACING HIS OR HER CHILDREN IN A PBMA CHILD'S PROGRAM, ACTIVITY OR EVENT, THE UNDERSIGNED,
ON HIS OR HER BEHALF AND BEHALF OF SUCH CHILDREN, HEREBY acknowledges that having his or her child or children participate in such activities may include inherent risks, hazards, and dangers that cannot necessarily be predicted or controlled. The Undersigned further understands that not all inherent risks, hazards and dangers can be eliminated, and that the inherent risks of the such activities can cause property damage, injury, illness, paralysis or death. Some of the activities such children may be involved with include, but are not limited to: wilderness travel and
activities, bouldering, rock climbing, crafts, mountain biking, ropes challenge courses, archery, rafting, swimming, horseback riding, fishing, overnight camping, and other program activities.
5. THIS RELEASE & WAIVER SHALL BE GOVERNED BY AND CONSTRUED UNDER THE APPLICABLE LAWS OF Province Of BC THE UNDERSIGNED further expressly agrees that the foregoing RELEASE, WAIVER AND INDEMNITY AGREEMENT is intended to be as broad and inclusive as is permitted by the law of Canada and that if any portion thereof is held invalid, it is agreed that the balance shall,notwithstanding, continue in full legal force and effect.
THE UNDERSIGNED HAVE READ AND VOLUNTARILY SIGNS THE RELEASE AND WAIVER OF LIABILITY AND INDEMNITY AGREEMENT,and further agrees that no one has made any oral representations, statements or inducement other than as set forth above in writing