Young Women's Resource Center Sign Up Form

Program Registration - Young Moms

Intake and Registration form for Young Moms programs.

I assume all responsibility for any accidents or injuries that may occur, and release the facilitators and Young Women’s Resource Center employees of all liability. In case of accident, injury or sudden illness, I request that necessary medical care be instituted. My physician/dentist may be contacted in case of medical treatment or as necessary and is authorized to release requested information as needed. The participant is responsible for all medical expenses.
Participant Name/Signature*
First Last
Date Signed*
Date Format: MM slash DD slash YYYY
Hospital Preference:*
Emergency Contact Name (1st)*
First Last
Emergency Contact Relationship to Participant (1st)*
Emergency Contact Phone (1st)*
Emergency Contact Name (2nd)
First Last
Emergency Contact Relationship to Participant (2nd))
Emergency Contact Phone (2nd)
Do you have any allergies?*
- Yes
- No
If you have any allergies, please list them here:
Participant medications (please list name and dosage):
Ongoing participant medical conditions:
Health Insurance Provider/Company:
I have answered these questions to the best of my knowledge. If I have any questions or concerns, I will speak with the program facilitator(s).
Participant Name/Signature*
First Last
Date Signed*
Date Format: MM slash DD slash YYYY
I understand that the YWRC is not responsible for any stolen, broken or lost personal belongings. I understand that the YWRC is not responsible for any personal injuries that may occur to my child(ren) and/or myself during participation in programming. In the event of accident, injury, or sudden illness; I give my consent for the YWRC staff to secure proper medical treatment for myself and/or my child(ren). I agree to be responsible for all medical expenses. I authorize the YWRC to provide basic demographic information to the United Way of Central Iowa who provides funding for this program. I give my permission for the YWRC staff/volunteers to transport myself and/or my child(ren) to YWRC Programs and any field trips planned. I give permission to the YWRC staff/volunteers to provide childcare for my child(ren) during group and understand children over six weeks old are required to go to childcare when at the center during group.
I give permission to the YWRC to use any photographs or video taken of myself/my child(ren) while participating in the program to use for promotional activities of the program or school.*
- Yes
- No
Participant Signature*
First Last
Date Signed*
Date Format: MM slash DD slash YYYY
Name
This field is for validation purposes and should be left unchanged.

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Empowerment and Therapy

Young Moms

Program Registration - Young Moms

Step 1 of 3 - Guardian Information

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Pregnancy and Child Information

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