YMCA Volunteer Application - Summer 2022
Welcome to the Summer 2022 Volunteer Application for the YMCA of the Seven Council Fires (formerly known as the "Sioux YMCA"). If you are filling out this application before a representative from your group has reached out to one of our staff members, please email our Social Responsibility Director, Kayla Payne, at kayla@siouxymca.org to ensure that this is the correct form for your group.
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Email *
PARTICIPANT INFORMATION
First and Last Name: *
What best describes you? *
Are you coming with a group? Insert group's name below.
Dates of Volunteering: (XX/XX/XXXX - XX/XX/XXXX) *
Date of Birth: *
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Gender Identity: *
Tribal Affiliation: (insert "none" if not applicable to you) *
Mailing Address: *
T-shirt Size: *
EMERGENCY CONTACT INFORMATION
Primary Contact Name: *
Relationship to Participant: *
Phone Number: *
Mailing Address: *
Email Address: *
Secondary Contact Name:
Relationship to Participant:
Phone Number:
Mailing Address:
Email Address:
HEALTH INFORMATION
All information provided is private and confidential. If this does apply to you, leave the answer field blank.
Are you covered by medical/hospital insurance? *
If yes, indicate the insurance carrier information below. *
Description of Health History:
Allergies:
Dietary Restrictions:
Have you received a complete COVID-19 vaccination? (If no, we ask you test negative 48 hours before arrival, submit proof of test, and wear a mask in all indoor spaces) *
MEDICATIONS
Please list ALL medications (including over-the-counter or nonprescription drugs) taken routinely. Bring enough medications to last the duration of the volunteer experience. Keep them in the original bottle/packaging that identifies the name of the participant, the name of the medication, the dosage, and the frequency of administration.
Medication Names, Dosage, and Time Taken Each Day (separate different medications with a ";"):
RELEASE
Check each statement to show you have read and agree.
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A copy of your responses will be emailed to the address you provided.
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