Camp Hero Registration 2017
Camp Hero my child will be attending:
_____ June 5 – 9 (Joint Base Pearl Harbor Hickam location)
_____ June 26 – 30 (Marine Corps Base Hawaii location)
I would like to register for the
Extended Day Version of Camp Hero,
**Available ONLY at Joint Base Pearl
Harbor Hickam location.
8:00 am – 4:30 pm.
Childs Name: ______________________________________________________________________
Age: _____
DOB: ______________
Mother/Legal Guardians Name: ________________________________________________________
Mother’s Phone: __________________
Father/Legal Guardians Name: ________________________________________________________
Father’s Phone: __________________
Mailing Address: ____________________________________________________________________
Email Address: _____________________________________________________________________
Branch of Service: ________________
Rank: ____________________
Has your child ever attended a Camp Hero program before? _________________________________
What school does your child attend? ____________________________________________________
Registration Fee for Camp Hero 8:00 – 1:00 pm: $95.00
(E6 and below $65.00)
(Additional online registration fee of $6 if registering online)
Payment type:
___ Cash
___ Check (Make payable to Armed Services YMCA)
Registration Fee for Camp Hero
Extended Day Version at JBPHH ONLY 8:00 – 4:30 pm: $145
(E6 and below $115.00)
(Additional online registration fee of $11 if registering online)
Payment type:
___ Cash
___ Check (Make payable to Armed Services YMCA)
Emergency Contact Information Form
Childs name: _______________________________________________________
Age: _____ DOB: _________________
Emergency Contacts: (Please provide TWO contacts)
Name: _____________________________________________________________
Phone number: _____________________________________________________
Name: (other than parent) _____________________________________________
Phone number: _____________________________________________________
Authorized person(s) to pick up / drop off child: (Please provide TWO contacts)
(1) Name______________________________________________________
Phone Number: ______________________________________________
(2) Name______________________________________________________
Phone Number: ______________________________________________
Primary care clinic: __________________________________________________
Name of primary care physician: ________________________________________
In case of an emergency and I am unable to give verbal consent, I hereby authorize the
ASYMCA of Honolulu to refer my child to the nearest emergency room.
Signature: _______________________________________
Date: ____________
Participant’s Full Name (Please print clearly) _______________________________________
HOLD HARMLESS, WAIVER OF LIABILITY, AND INDEMNITY AGREEMENT
For and in consideration of permission granted by the United States Marine Corps for me to
enter Marine Corps Base (MCB) Hawaii, Kaneohe Bay, Hawaii, on 28 June 2017 to participate
in the ASYMCA sponsored Jane Wayne Day, and being informed of all the conditions that I
will encounter during this period of time, to include, but not limited to, all natural environments,
transportation on and off the installation and activities, I forever discharge and hold harmless the
United States, United States Marine Corps, and all of its officers and personnel, employees,
representatives, and their successors or assigns, including the Commanding Officer, MCB
Hawaii, Kaneohe, Hawaii from any and all liability under the Federal Tort Claims Act (28
U.S.C. Sections 1346(b), and 2671-2680), or other statutes addressing personal injury or
property losses.
I also waive all claims, demands, damages, actions, or suits of any nature or legal basis against
the United States of America, United States Marine Corps, and their agencies, departments,
officers, employees, personnel, and their successors or assigns, including the Commanding
Officer, MCB Hawaii, arising from any injury or alleged injury, including death, and property
damage or loss that occurs incident to my entering upon, engaging in any activities that are
associated with the ASYMCA sponsored Jane Wayne Day, including, but not limited to,
engaging in physical activities, transportation on and off the installation, and/or use of any
facility or equipment located on MCB Hawaii, wherever the loss or injury may occur.
I understand that no special measures have been taken to specifically address the needs,
tendencies and care of participants from the ASYMCA sponsored Jane Wayne Day, during
this event. Therefore, I fully appreciate the special risks and understand that I am solely
responsible for my care.
I understand that this waiver is legally binding on me and my heirs, executors, and administrators.
I also acknowledge that I am aware of the risks involved in my duties and responsibilities by
participating in the ASYMCA sponsored Jane Wayne Day.
I further acknowledge that I have carefully read this release, understand the contents thereof, and
sign this release as my free and voluntary act.
____________
Date
_______________________________________
Signature of Participant
_______________________________________
Participant’s Parent/Guardian (if applicable)
Camp Attending: ______________________________________
Child’s Name: _________________________________________
Parent’s Name: ________________________________________
Armed Service YMCA Release and Waiver Liability
I hereby voluntarily and knowingly assume all risks and dangers inherent and incidental to
the activities of Armed Services YMCA programming for myself and my family members. I will
not hold the Armed Services YMCA of Honolulu liable for any injuries incurred during
programming or 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 Armed Services YMCA of Honolulu, or its employees, volunteers, or agents.
I do hereby authorize the Armed Services YMCA of Honolulu as agent for all Armed Services
YMCA Members, to consent with respect to the minors, to any, 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 licensed physician and surgeon licensed, whether
such diagnosis or treatment is rendered at the office of the physician or at the hospital. I
understand that the Armed Services YMCA Honolulu 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 Armed Services YMCA of Honolulu 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
Armed Services YMCA of Honolulu personnel.
Parent Signature:________________________________________Date:______________
Consent to Photograph, Film, or Videotape for Non-Profit Use
I hereby grant full permission for myself, my child, and/or my family members to be
photographed by the Armed Services YMCA of Honolulu staff for any legitimate purpose
without payment or compensation. I also hereby consent to the participation in interviews,
the use of quotes, and the taking of photographs, movies, or video tapes. I also grant to the
Armed Services YMCA of Honolulu the right to edit, use, and reuse said products for nonprofit
purposes including use in print, on the internet, and all other forms of media. I also hereby
release the Armed Services YMCA of Honolulu and its agents and employees from all claims,
demands, and liabilities whatsoever in connection with the above.
By signing below, you acknowledge that your household has received, read, and understood
the Armed Service YMCA Release and Waiver Liability and the Consent to Photograph,
Film, or Videotape for Non-Profit Use.
Parent Signature:________________________________________Date:______________
Must be completed and stamped by Child’s Medical Provider if your child has conditions that may require medical
intervention. This form will need to be returned to the Office Manager before your child can be registered.
Child’s Name_________________________________
Parent Contact Phone #_________________
E-mail address________________________
General Medical Action Plan
My Child has NO known medical conditions or allergies that require intervention (if you checked
this box you do not need to fill this form out any further.
My child has the following conditions that may require medical intervention (please specifyallergies, asthma, etc):
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
The following must be completed and stamped by Child’s Medical Provider:
Diagnosis:
Medicine Name:
Dosage:
Trigger:
Side Effect:
When to administer medication:
When to repeat medicine:
Contact parents and/or emergency services (911), if:
Diagnosis:
Medicine Name:
Dosage:
Trigger:
Side Effect:
When to administer medication:
When to repeat medicine:
Contact parents and/or emergency services (911), if:
Physician’s Printed Name: ___________________________________________________________
Physician’s Signature and Date _______________________________________________________
Physician’s Phone Number___________________________________________________________
Page 1 of 2
Must be completed and stamped by Child’s Medical Provider if your child has conditions that may require medical
intervention. This form will need to be returned to the Office Manager before your child can be registered.
Child’s Name_________________________________
Parent Contact Phone #_________________
E-mail address________________________
--------Below information to be completed by the parent or guardian-------I authorize ASYMCA staff to administer the above medications and take the above actions or precautions
to my child according to the physician’s instructions. I understand that I am responsible for assuring that
medication made available to ASYMCA is current (not expired) and I will advise ASYMCA of any changes to
this medical action plan.
Signature of Parent:
________________________________________________Date:________________________________
Parent/Guardian Authorization of Release of Medical Information:
I, _________________________________________, hereby authorize the release of medical
information relevant to this medical action form.
________________________________________________
Signature
__________________________
Date
Home Address:_____________________________________________________________________
Signature of Parent:
________________________________________________Date:________________________________
Page 2 of 2