By signing, I acknowledge that I am up-to-date on vaccinations, which includes being fully vaccinated for COVID-19. I understand that “fully vaccinated for COVID-19” means one of the following applies to me:
(A) It has been at least two weeks since my second dose in a 2-dose series of the Pfizer or Moderna vaccines and a booster shot if eligible, OR
(B) It has been at least two weeks since my single dose of the Johnson & Johnson vaccine and a booster shot if eligible.
I also agree to notify YLI in the event that I develop symptoms or if I come in close contact with someone who has tested positive for or developed symptoms of COVID-19. I acknowledge that symptoms of COVID-19 include, but are not limited to, fever or chills, cough, shortness of breath or difficulty breathing, fatigue, muscle or body aches, headache, new loss of taste or smell, sore throat, congestion or runny nose, nausea or vomiting, and diarrhea.
In addition, I understand and also agree to the following:
(A) The health information provided is correct to the best of my ability.
If an illness or injury develops, I authorize YLI to provide first aid and seek medical care as appropriate, including providing transportation to obtain medical care.
(B) I authorize YLI program staff to release medical and health insurance information to the medical care unit in the event that I require medical care.
(C) I grant permission to the attending physician and/or the attendant medical facility staff to employ such diagnostic procedures and medical treatment as deemed necessary.
(D) I understand that I am financially responsible for all medical charges that may incur. YLI is not responsible for medical expenses.
(E) This Health form is valid through 7/1/26. I will notify the YLI staff if there are changes in my health.