Engaging Youth in Leadership and Community Service

Adult Volunteer Health Form & Liability Release

ADULT VOLUNTEER HEALTH FORM & LIABILITY RELEASE

Youth Resources requires a health form and liability release for every long-term adult volunteer. Please complete the health form and liability release below and provide your e-signature.

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

VOLUNTEER DETAILS

EMPLOYMENT INFORMATION

PARTNER INFORMATION

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

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.

ADDITIONAL HEALTH-RELATED INFORMATION

VOLUNTEER 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 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.
Please type your name above as your e-signature.
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