This questionnaire is designed to aid WYF volunteers and mentors in anticipating any health concerns that might affect your child’s safety or learning.

  • MEDICAL

  • INSURANCE

  • MEDICAL HISTORY

  • LIFE-THREATENING CONDITIONS

  • WYF provides breakfast during each session. Meals are also served on WYF outings. *an additional form must be completed for food allergies

    MEDICATION

  • SPEECH/LANGUAGE

  • AUTHORIZATION FOR EMERGENCY MEDICAL TREATMENT

    I understand the information given above will be shared with appropriate individuals (volunteer/mentors of WYF) to provide for the health and safety of my child. If either I or an authorized emergency contact person cannot be reached at the time of a medical emergency, I authorize WYF volunteers/mentors to send my child to the most easily accessible hospital or physician. I understand I will assume full responsibility for payment of any transport or emergency medical services rendered.