RYLA Camp YOUTH Health Center and SNJ Waiver Form - 2022 Header Image

RYLA Camper Health Form, Authorization to Treat, and SNJ Liability Waiver

**Eligibility Requirements: Rotary Youth Leadership Awakening is for rising seniors nominated by Rotary Clubs in the 5180/5190 Districts.

This waiver is required for every attending participant. All waivers MUST be filled out by the LEGAL GUARDIAN of the participant if they are under the age of 18.

Camper's Name*
Camper's birthday*
Which RYLA session will your camper attend?*
Please review the sessions offered. If you are unsure of your session, recheck with the Rotary.

Parent/Guardian Information and Emergency Contact

Parent/Guardian Name*
Emergency Contact (other than name listed above)*

Health Information

Does Camper have medical insurance?*
Does the Camper have a history of any of the following medical conditions?*
Does Camper have any of the following mental health concerns?*
Does Camper have food allergies or dietary requirements?*
Does Camper have any environmental allergies?*
Does Camper have any allergies to medication?*
Does Camper carry an epi-pen?*
Does Camper know when and how to use their epi-pen?
Please indicate what over the counter medications you allow SNJ medical staff to administer to the camper as needed*
Will the camper need to take medication, prescription OR over-the-counter, at camp?*
Date of Camper's last tetanus shot?

Medication Information

List all prescription AND over the counter medications that you will send with your child. Please state all information clearly for your child's safety. If there are special instructions or changes be sure to speak with the nurse at in-processing. If your child is bringing an inhaler, please note at this time. You have the option of bringing 2 inhalers to camp to keep one with the Camp Nurse and one with the camper at all times.

Medication 1 Time of Administration
Medication 2 Time of Administration
Medication 3 Time of Administration

Participant Demographic Information

Please answer the following questions in relation to the participant who is attending camp. This information is for grant-based reporting and to ensure we are meeting the needs of the communities we strive to serve.

Select the racial/ethnic identity you identify as:
Do you qualify for free or reduced lunch at your school?

Authorization for Treatment

I hereby give permission to Sierra Nevada Journeys to seek emergency medical treatment. In the case of severe allergic reaction (anaphylaxis), I give permission for Sierra Nevada Journey's staff members to act in accordance with their emergency training and administer epinephrine via auto-injector and/or oral antihistamines. I agree to the release of any records necessary for treatment, referral, billing, or insurance purposes. I give permission to Sierra Nevada Journeys to arrange necessary related transportation for me/my child. In the event I cannot be reached in an emergency, I hereby give permission to the physician selected by Sierra Nevada Journeys to secure and administer treatment, including hospitalization, for the person named above.Information in this paperwork may be given to the physician.I agree to incur all costs related to any medical emergency for the person named above.

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Immunization Attestation

I hereby attest that the Grizzly Creek Ranch attendee has completed all the necessary immunizations required for public school attendance or have a state-approved exemption for public school attendance.  I declare that the above statement is true and accurate to the best of my knowledge.

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Communicable Disease Liability Waiver

In consideration of participating on behalf of Sierra Nevada Journeys programming and related activities, I acknowledge and agree that participation includes possible exposure to and illness from infectious diseases including but not limited to MRSA, influenza, and COVID-19. While particular rules and personal discipline may reduce this risk, the risk of serious illness and death still exists. I knowingly and freely assume all such risks, both known and unknown, even if arising from the negligence of Sierra Nevada Journeys or other participants, and assume full responsibility for my participation. I willingly agree to comply with the stated terms, conditions, and community agreement for participation as they pertain to protection against infectious diseases.

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Liability Waiver for Injury to Persons and/or Property

I grant permission for my child, or if over the age of 18 years, accept to participate in all activities and camp programs, including but not limited to, ropes course, off-site trips by van, bus or other designated vehicle/s, understand that appropriate supervision is provided under the State of California requirements for residential camp programs. I also understand that during my child’s participation at Sierra Nevada Journeys’ (SNJ) Grizzly Creek Ranch Campus, s/he/I may be exposed to a variety of risks and hazards, foreseen or unforeseen, which cannot be eliminated without fundamentally altering the unique character of the program. Those hazards include, but are not limited to, hiking/walking/running outside, snakes, insects, and large animals; sunburn, and heatstroke, dehydration, hypothermia, and other mild or serious conditions or injuries; falling and rolling rocks; drowning; lightning, and unpredictable forces of nature (including weather that may change to extreme conditions without notice), etc. As a condition of my child’s participation in the program, I acknowledge that participation is entirely voluntary, and I agree to assume full responsibility for the risks that participation may entail. I voluntarily agree to release, indemnify, and hold harmless Sierra Nevada Journeys, its officers, directors, agents, and employees, to the fullest extent permitted under the law. I understand that this release covers all liabilities, charges, expenses and costs on account of or by reason of any such injuries, claims, actions, or other legal proceedings however occurring or damages growing out of the same. 

Sierra Nevada Journeys is not responsible for lost, stolen, or damaged articles. I authorize Sierra Nevada Journeys to have and use photographs, slides, and/or video my child/myself listed on this form for marketing and/or advertising purposes (only), and I hereby consent to and authorize such use without seeking remuneration.

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