Social Responsibility and Community Impact (SRCI) Agreement

My child has permission to participate in all Young Men’s Christian Association (YMCA) of Greater Indianapolis Youth Empowerment activities, including field trips and transportation, where applicable. The health history provided is correct as far as I know, and my child named above has permission to engage in all activities except as noted. I grant permission for YMCA staff to monitor my child’s behavior and performance in school and to obtain copies of report cards, attendance, disciplinary, and other school records as it relates to program goals. I understand that my child is solely responsible for his/her actions. Therefore, if actions warrant, and my child’s behavior is not acceptable (according to YMCA guidelines), I understand that my child may be sent home at any time and at my expense. I grant permission for photographs, written/art work, quotes, videos or other media which may include my child, to be used in media releases which benefit the YMCA.
In the event of an emergency, I hereby give permission to the physician selected by the YMCA to order x-rays, routine tests, and treatment for the health of my child. In the event that I cannot be reached in an emergency, I give permission to the physician selected by the YMCA to secure proper treatment for, hospitalize, and/or to order injections, anesthesia, or surgery if necessary. In the event it becomes necessary for the YMCA staff to give consent for us, we agree to hold such person and the YMCA free and harmless of any claims, demands or suits for damages arising from the giving of such consent so long as the treatment is administered by or under the supervision of a licensed physician.
By acknowledging this form, I expressly assume the risk of damage or harm to person or property. Accordingly, neither the YMCA nor any of its agents, employees, volunteers, or invitees shall be liable to me or any of my family, agents, employees, volunteers, servants, or invitees for any damage to persons or property when and to the extent that any such damage or injury may be caused, either proximately or remotely, wholly or in part, by any act or omission, whether negligent or not, of the YMCA or any of its agents, employees, volunteers, or invitees or due to the condition, design, or defect in the building, its mechanical systems, or its equipment.
I AM LEGALLY COMPETENT TO ACKNOWLEDGE THIS AGREEMENT AND HAVE ACKNOWLEDGED THIS AGREEMENT VOLUNTARILY WITHOUT ANY INDUCEMENT. I REPRESENT THAT I AM AT LEAST EIGHTEEN (18) YEARS OF AGE, OR, IF APPLICABLE, I AM A PARENT OR GUARDIAN LAWFULLY ABLE TO SIGN ON BEHALF OF A PARTICIPANT UNDER EIGHTEEN (18) YEARS OF AGE.