I consent to the enrollment of the child listed above in this facility and have been advised and read all of the policies regarding administration of
medications, fees, transportation, and the services provided by the facility and the Office of Children and Family Services regulations under which it operates. All community members are allowed to come and go from the space as needed, as this is a drop-in center.

• The YMCA assumes responsibility for my child’s well being during the hours of operation in which my child attends the program.

• In the event of an emergency, the YMCA will make every effort to contact me. If I cannot be reached, the YMCA is authorized to act for me
according to their best judgment in an emergency requiring medical care or surgery. The physician selected may hospitalize, secure proper treatment for, or order injection, anesthesia, or surgery for my child.

• I am responsible for the cost of all medical treatment and care.

• I have provided information on my child’s special needs (allergies, diet, disabilities, and/or medical information) to the provider, as may be necessary to assist the facility in properly caring for my child in case of an emergency. I agree to review and update this information whenever a change occurs and at least once every six months.

• The information on this form is complete and accurate. I have provided the YMCA with all of the necessary information to properly care for my child’s needs.

• I must notify the YMCA staff immediately of any changes on this form.

• The YMCA’s responsibility for my child begins when the child has reached the program and checked in with YMCA staff. It is my responsibility to notify the YMCA staff if my child will be absent from the program.

• 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.

• YMCA staff and volunteers are not allowed to baby sit or transport children at any time outside of the YMCA program.

• The YMCA is mandated, by state law, to report any suspected cases of child abuse or neglect to the appropriate authorities for investigation.

My signature acknowledges my understanding of and agreement to the above:

Photos/Video
I give permission for my child to be photographed or videotaped and to have those photos used in program and/or in YMCA approved materials and social media. The United Way may also use these photos/videos in publications and promotional pieces. I will not be informed or reimbursed for such photographs.

Food
Through a collaboration with Foodlink, we are proud to provide a healthy snack option for all youth. To ensure the safety of participants, no outside food is permitted.

My signature acknowledges my understanding of and agreement to the above:

In consideration of membership with the YMCA of Greater Rochester, I agree to release, indemnify and hold harmless the YMCA, and its officers, employees and volunteers, with respect to any and all accidents, injuries, losses or damages to person or property that result from my/my child’s participation in YMCA programs or facilities, whether arising from the negligence of the YMCA or otherwise, to the fullest extent permitted by law. I do further agree on behalf of myself, and my heirs, executors and administrators, to waive, release and forever discharge any and all rights and claims for damages which may have accrued, or which may hereafter accrue, to me/my child arising out of or connected with participation in the YMCA programs, use of the YMCA facilities and property, or use of equipment within the YMCA facilities and property.

I understand that even when every reasonable precaution is taken, accidents can sometimes occur. I further understand that the activities of the YMCA have inherent risks of serious injury and I hereby assume all such risks and hazards incidental to my or my family’s participation in the programs, use of the facilities, or use of equipment within the facilities.