EMERGENCY CONTACT INFORMATION
Emergency contact should be someone other than partner, if listed above.
Please list contact other than partner, if listed above.
VOLUNTEER HEALTH INFORMATION
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.
ADDITIONAL HEALTH-RELATED INFORMATION
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 the volunteer named above. 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 the volunteer named above. Emergency authorization valid from January 1, 2024 through July 31, 2025.