YVCHR WAIVER FORM


Part 1: YOUTH VOLUNTEER PROFILE

YOUTH VOLUNTEER INFORMATION
Name *
Name
Date or Birth *
Date or Birth
Address *
Address
Home Phone #
Home Phone #
YOUTH AGREEMENT
-To be on time and work all scheduled project hours OR notify YVC in advance if you cannot -To maintain a positive attitude and show respect to everyone at the project -To attend any required orientation and training and to participate in all project activities -To keep all personal electronic devices off and out of sight
PARENT/LEGAL GUARDIAN INFORMATION
Parent/Guardian Name *
Parent/Guardian Name
Parent/Guardian Phone # *
Parent/Guardian Phone #

part 2: YVC PARENT/LEGAL GUARDIAN WAIVER

Youth Volunteer's Name *
Youth Volunteer's Name
Please review the following *
RISK DISCLOSURE: I understand that adult supervisors will accompany my child on all projects and activities. I also understand that the supervisors may be volunteers and that the project or activity will involve normal level of risk associated with such a project or activity. I agree that this form shall waive any rights, claims of responsibilty or liability, or cause of action resulting from personal injury to my child in the YVC program and agree to indemnify the partner agency and its employees or representative from any claims MEDICAL CARE AUTHORIZATION: At any time due to such circumstances as accident or sudden illness I hereby give permission for emergency medical treatment to be obtained for my child. I understand that a YVC representative of the partner agency will call me prior to leaving or upon arrival at the emergency destination, and that I will be responsible for all related expenses incurred (i.e. ambulance or taxi costs, etc) PHOTOGRAPHIC/TRANSPORTATION RELEASE: In the event my child is photographed or filmed for promotional purposes while participating in a YVC project, the photo or video may be used by YVC or any of its related agencies for promotional purposes. I authorize YVC and/or partner agency staff to transport my child in their vehicles if needed PARENT/LEGAL GUARDIAN RESPONSIBILTY: I will inform YVC of any special need or condition my child has. I understand withholding this information is unfair to my child and to the YVC leader entrusted with my child’s safety. I will be punctual when dropping off/picking up my child from projects, both for his/her safety and as a courtesy to YVC and its partner agencies. I understand that violating these policies may lead to my child’s exclusion from YVC programs
Emergency Contact #1 *
Emergency Contact #1
(if we are unable to reach you)
Emergency Contact Phone # *
Emergency Contact Phone #
Emergency Contact #2
Emergency Contact #2
Emergency Contact Phone #
Emergency Contact Phone #
Does your child have any allergies? *
Is your child currently under medical care? *
Name of Health Care Provider/ Family Physician *
Name of Health Care Provider/ Family Physician
If there is none, please put 'na'
Please check all that apply for the youth named above
Please note, this information is kept confidential and will not affect the youth's ability to participate in the YVC program, It is collected for anonymous grant reporting and program improvement purposes only
sign below to acknowledge you have read and understand this waiver, agree to its provisions, affirm that you are the parent/legal guardian of the child named above, and to verify all of the information you have given is correct