Operation Hero

Participant Information Sheet

Student Information:
Last Name: _____________________ First Name: _________________
Age: ______________

DOB: ____________

Sex:

MI: ______
Grade: _____

Known Allergies to Food/Medication: ________________________________________

Current Medical Conditions: ________________________________________________
List Medications Currently Taking: ___________________________________________
Please List Other Siblings or Family Members in the Home:
Name

Age

Grade

Teacher

______________________

________

______

__________________________

______________________

________

______

__________________________

______________________

________

______

__________________________

______________________

________

______

__________________________

Please describe your childs strengths or best qualities:

_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
Please describe three goals you have for your child during Operation Hero:
1._________________________________________________________________________
2._________________________________________________________________________
3._________________________________________________________________________

Childs Behaviors:
Please place an X next to the words or behaviors that you feel apply to your child
___ Happy

___ Sad

___ Easy Going

___ Irritable

___ Thoughtful

___ Impulsive

___ Stubborn

___ Focused

___ Temper Outbursts

___ Considerate

___ Disobedient

___ Withdrawn

___ Outgoing

___ Daydreaming

___ Focused

___ Academic Problems

___ Confident

___ Fearful

___ Overactive

___ Fearless

___ Low Energy

___ Sensitive

___ Short Attention Span

___ Sleeping Problems

___ Helpful

___ Distractible

___ Shy

___ Proud

___ Nervous

___ Peer Conflicts

___ Worried

___ Lonely

___ Kind

___ Difficulty Making Friends ___ Fighting with Siblings

___ Physical Fights

___ Runs Away from Adults

___ Other: ____________________________

___ Any Recent Losses or Changes in Your Family (Please Explain):

_______________________________________________________________________
_______________________________________________________________________
Please describe your childs support system (including family, friends, or community
support):
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________

Family Information:
MOTHER / STEPMOTHER / LEGAL GUARDIAN (circle one):
Name: _____________________ Military or Non-Military (circle one) Rate/Rank: _____
Address: _______________________ City: _______________ State: ____ Zip: _______
Home Telephone: _________________________ Cellular Telephone: _________________
Home Email Address: _________________________________________________________
Employers Name: ___________________________ Occupation: _____________________
Employers Address:_________________ City: ____________ State: ____ Zip: _______
Work Telephone: _____________________ Work Email Address: _____________________

FATHER / STEPFATHER / LEGAL GUARDIAN (circle one):

Name: _____________________ Military or Non-Military (circle one) Rate/Rank: _____
Address: _______________________ City: _______________ State: ____ Zip: _______
Home Telephone: _________________________ Cellular Telephone: _________________
Home Email Address: _________________________________________________________
Employers Name: ___________________________ Occupation: _____________________
Employers Address:_________________ City: ____________ State: ____ Zip: _______
Work Telephone: _____________________ Work Email Address: _____________________

Emergency Information:
PLEASE LIST AN EMERGENCY CONTACT. IN THE EVENT THE PARENT(S) ARE
UNAVAILABLE, THIS PERSON WILL ALSO BE CONSIDERED AUTHORIZED TO PICK
UP YOUR CHILD(REN):
Name

Home Phone

Alternate Phone

_______________________________________________________________________
PLEASE LIST PERSONS AUTHORIZED TO PICK UP YOUR CHILD(REN):
Name

Home Phone

Alternate Phone

_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________

Please Read and Sign Below:

In case of illness, accident, or injury to my child, I hereby authorize the San Diego Armed
Services YMCA as agent for the undersigned, to consent with respect to the minors, to any xray examination, anesthetic, 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 physician and surgeon licensed under the provisions of the California Medical Practice
Act on the medical staff of any hospital, whether such diagnosis or treatment is rendered at the
office of the physician or at the hospital. I understand that the San Diego Armed Services
YMCA is not responsible for costs incurred for medical care.
_______________________________________________________________________
Signature of Parent

Date

Operation Hero Parent Statement of Understanding

By signing below, the parent/guardian acknowledges and agrees to the following
1. I give consent for my child to participate in the Armed Services YMCA
Operation Hero program at ____________________ Elementary School.
2. I understand it is my childs responsibility to go directly to the Operation Hero
meeting area immediately following school.
3. I understand that if my child does not come to the meeting place, the
following steps will be taken:
The Lead Teacher will check with classmates and the main office to
inquire whether or not the child was in school.
If the child was in school, the Lead Teacher will call home to ensure that
parents know the child did not report to Operation Hero
4. I understand that the Operation Hero facilitator is not responsible for my child
after the end of the program hours and will not stay after program hours with
my child.
5. I understand that I must sign a permission slip for my child to be able to walk
home.
6. I agree to waive and release, (hold harmless) the Armed Services YMCA its
agents and employees from any and all claims or demands arising out of
participation in the Operation Hero Program.
7. I understand I am ultimately responsible for my childs behavior and will be
held financially liable for any damage my child may cause to materials and/or
equipment during the Operation Hero Program.
8. I have received, read, understand, and agree to comply with the policies and
procedures of the Armed Services YMCA Operation Hero Program.

_________________________________________

________________________

Parent/Guardian Signature

Date

CONSENT FOR PHOTOGRAPHY

Pictures may be taken of the children while they are participating in Operation
Hero. These photographs will be used for program promotion and fundraising.
I, __________________________________, hereby give my written permission for
my child, _____________________, to be photographed by San Diego Armed
Service YMCA staff.
Parent/Guardian (signature) __________________________ Date ________

Permission to Walk Home

I understand that I am responsible for my child when Operation Hero ends at 4:15
p.m. on Tuesdays and 2:45 p.m. Thursdays. I give my permission for my child
_____________________ to walk home from Operation Hero at Hancock
Elementary School. I have explained to my child that he/she needs to walk straight
home and that someone will be there when they arrive.
_________________________
Parent Signature

_________
Date

Youth and Community Outreach Department

Release of Liability Form: Adults and Minors

Parent/Guardian Name(s) (print)_____________________________________________________________________

Parents Date(s) of Birth (same order)__________________________________________________________________
Address________________________________City_________________Zip____________Military Housing? Yes/No
Email Address________________________________________Service Branch_____________________Rank______
Home Phone__________________________Work__________________________Cell__________________________
Emergency Contact________________________________________________________________________________
EC Home Phone_______________________EC Work_______________________EC Cell______________________
Minor Children Participating:
Name______________________________________________________________Date of Birth___________________
Name______________________________________________________________Date of Birth___________________
Name______________________________________________________________Date of Birth___________________
Activity or Group_________________________________________________Date(s)___________________________
Location_________________________________________________________________________________________

I, the undersigned parent/person having legal custody/guardianship of the above said minor, give permission for the minor to
participate in the San Diego Armed Services YMCA program described above. I hereby grant full permission for my child
and/or myself to be photographed by the San Diego Armed Services YMCA staff for any legitimate purpose without payment
or compensation. The minor is physically able and mentally prepared to participate in all activities as described in the
announcement for the program. I hereby voluntarily and knowingly assume all risks and dangers inherent and incidental to the
activities of the program. I will not hold the San Diego Armed Service YMCA liable for any injuries incurred during the
program or while my child(ren) is/are 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 San Diego Armed Services
YMCA, or its employees, volunteers, or agents.
I do hereby authorize the San Diego Armed Services YMCA as agent for the undersigned, to consent with respect to the minors,
to any x-ray examination, anesthetic, 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 physician and surgeon licensed under the
provisions of the California Medical Practice Act on the medical staff of any hospital, whether such diagnosis or treatment is
rendered at the office of the physician or at the hospital. I understand that the San Diego Armed Services YMCA 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 San Diego Armed Services YMCA 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 San Diego Armed Services YMCA personnel.
_______YES My child(ren) can receive a healthy snack

_______NO My child(ren) cannot receive a healthy snack

Food Allergies, if any:______________________________________________________________________________

My Child(ren) will _____ Walk Home _____Be picked up. Person(s) who may pick up child(ren)____________________

****Parent/Guardian (Signature)____________________________________Date___________________****