Youth Advocate Permission Form
The following information will remain confidential and will not be shared with anyone without the prior
consent of the youth advocate.
Name:
Date:
Address:
Home Phone:
Cell Phone:
E-mail:
Facebook:
Name of School:
Grade:
Please list all extra-curricular activities and interests in which you are currently involved, and list the days and hours you
attend these activities (sports, clubs, hobbies, etc.).
Activity (Spanish Club)
Days (Mondays and Thursdays)
Hours (3pm-5pm)
How did you hear about Day One’s Youth Advocate program?
Have you ever participated in Day One’s Youth Advocate program?
Yes
No
Please describe any experience you have had with young people between the ages of 11and 16 (coaching, tutoring,
counseling, etc.).
Please explain your reason(s) for wanting to become a Youth Advocate.
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What do you think is the most important issue facing today’s Youth Population?
What contribution(s) can you make towards the Youth Advocate program?
Please contact Claudia Morales with questions or concerns:
Phone: 626-229-9727
Email: claudia@dayonepasadena.org
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Youth Advocate Parent Consent Form
Participant’s Name:
Age:
Address:
City:
Zip Code:
Home Phone: (
School:
)
Cell Phone: (
)
Dietary Restrictions:
Parent/Guardian Name:
Cell Phone: (
)
Work Phone: (
)
Other Adults Child Can Be Released to:
MEDICAL INFORMATION
Medical Insurance Carrier:
Policy number:
Regular Physician’s Name:
Phone number:
Medication(s) if any:
Dosage:
List any allergies:
Is there anything we should be aware of to make your child more comfortable during this activity? Emergency Contact
Name:
Relationship:
Emergency Phone:
I ___________________________release the Day One staff and adult chaperones from any and all liabilities or responsibilities
pertaining to accidents, injuries, or complications from any Day One activities. I authorize Day One staff and adult chaperons to
transport my child in their personal or hired vehicles to and from Day One activities, if necessary. I authorize the Day One staff and
adult chaperones to transport the above named participant to the nearest hospital in case of injury or suspected injury while the
participant is involved in a Day One activity. I authorize the hospital attending physician to administer the necessary emergency
medical care to the above-mentioned participant upon his/her arrival at the hospital. I realize that Day One will not assume
responsibility for the payment of medical fees or expenses incurred.
To promote, evaluate, or otherwise describe Day One’s programs and activities, I give permission to Day One and its agents, to use in
connection with any publication (including but not limited to brochures, booklets, videotapes, reports, press releases, web sites, and
exhibits) any image or recording in which my child, a minor, appears, to use and cite any comment(s), verbal or written, made by
said minor about the program, and to use said minor’s name in connection with any publication and in such manner as determined
by Day One.
I further understand that this is a drug-free volunteer youth group and that my child is expected to adhere to Day One Rules and
Regulations as outlined in the Youth Advocate program.
Parent Signature:
Date:__________________________________
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