D6200 - RYLA+ 2023 Medical Release
Name of Sponsoring Rotary Club: Participant's Full Name: Sex: Grade: Age: High School (if applicable): Family Physician’s Name: Phone #: Name of Primary Insurance Policy:
Date of last Tetanus shot: Is the participant allergic to Tetanus Booster?
Has participant previously had appendix removed, fainting spells, asthma, heart trouble , convulsions, or diabetes? Allergies to food or medicine? Specify: Anything other to note (i.e. recent traumatic injury): Has the participant ever had an anaphylactic reaction? Is the participant required to carry an epinephrine auto injector?
Will medication be taken at camp? If yes, please fill out below: Activities to limit: Does Participant have any Existing Medical Conditions/Special Needs that need to be noted by staff:
I consent to (Participant’s Name) (hereinafter “participant”) participating in RYLA. The participant has permission to engage in all prescribed activities, except as noted above. It is also understood that all rules and regulations for this event will be enforced and any violation by the participant will result in the participant needing to leave RYLA which could include a call to a parent/guardian to request pick-up of the participant. In consideration of participation in this event, I agree (or if participant is under 18, legal guardian agrees on behalf of the participant) to fully and forever release, discharge, indemnify and hold harmless Rotary District 6200, any sponsoring Rotary clubs, and Leader N U LLC., their agents, servants and employees, successors, insurers, assigns, and all other persons, firms or corporations who might be liable, from any and all claims, demands, damages, charges, costs rights or causes of action of whatever nature, present or future, whether the same be known, anticipated or unanticipated, resulting from or arising out of participation in this event. The participant (or legal guardian) also hereby authorizes any medical treatment required by the participant while in attendance at this event. Described above are any special medical or other needs required by the participant, and if necessary event personnel will be notified of any other special needs or information required.Other person to notify in case of an emergency: Emergency Contact Phone #: (If Participant is under the age of 18, a parent or legal guardian will need to sign)Signing Parent/Guardian Full Name: Relationship to Participant: Date Signed:
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Document Name: D6200 - RYLA+ 2023 Medical Release
Agree & Sign