Volunteer Medical Form

This information is for official and medical confidential use only and will not be released to unauthorized persons.

Must be different than parents/guardians listed above.

Are there any medications or treatments that will be required while you are volunteering?
Please list all allergies--including seasonal, insect bites/stings, etc.--that you may have.
Please list any physical conditions that you have (back pain, heart condition, physical disability, visual impairment, etc.). Please email a separate sheet to YC with further details if necessary.

If over 18, sign below. If under 18, parent/guardian signs below.


(YC will also call parent/guardian or emergency contact and follow instructions of the attending physician.)
Please list alternative procedure.