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Health Form & Liability Release

HEALTH FORM & LIABILITY RELEASE

Youth Resources requires a health form and liability release for every student participant. A parent or guardian should complete the health form and liability release below and provide their e-signature. These forms must be renewed annually and should be submitted promptly upon request from a YR staff member. The form below will cover students’ participation from May 1, 2026-July 31, 2027.

If you have any questions regarding the health form or liability release, or you run into any issues completing the form, please call YR at 812-421-0030. Thank you!

Step 1 of 2
Select the YR program(s)/event(s) for which you are submitting this form:

STUDENT DETAILS

Date of Birth
Preferred Pronouns
Please include student cell so we can contact your student while they are at YR programming.
Leave blank if student does not have a cell phone.
Important and/or emergency information will always be communicated to parents/guardians as well as students.
Please include student email so we can email pertinent information regarding their participation in YR programs.
PERSONAL email preferred, not school email.
Leave blank if student does not have an email address.
Important and/or emergency information will always be communicated to parents/guardians as well as students.

PARENT 1 INFORMATION

Parent 1 Name

PARENT 2 INFORMATION

Parent 2 Name

ADDITIONAL ADDRESS

Parents who live separately please use this box to provide an additional address.
This is the address for:

EMERGENCY CONTACT INFORMATION

Emergency contact should be someone other than the student's parents/guardians.
Emergency Contact Name
Please list contact other than parents/guardians.

STUDENT HEALTH INFORMATION

Date of Last Physical Exam
Family Physician Name
Dentist/Orthodontist Name
Preferred Hospital

MEDICAL INSURANCE

Do you carry medical insurance?

COVID-19 VACCINATION INFORMATION

This information is for YR records only. The choice to vaccinate or not does not impact any student's program involvement eligibility.
Check one:

OVER-THE-COUNTER MEDICATION

Can we give your child over-the-counter medication if needed?

ADDITIONAL HEALTH-RELATED INFORMATION

PARENT/GUARDIAN SIGNATURE

Authorization for treatment: I hereby give permission to the medical personnel selected by the Youth Resources staff to order x-rays, routine tests, treatment, and necessary transportation for my child. In the event I cannot be reached in an emergency, I hereby give permission to the physician selected by the Youth Resources staff to secure and administer treatment, including hospitalization, for my child named above. Emergency authorization valid from May 1, 2026 through July 31, 2027.
Parent/guardian of student please type your name above as your e-signature.
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