Emergency Contact Form

Participant Name (name most commonly used)

First NameLast Name

Legal Name

First NameLast Name

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Participant or Parent E-mail

example@example.com

List any medical instructions or allergies we need for an emergency.

1st Emergency Contact

First NameLast Name

Phone Number

Format: (000) 000-0000.

E-mail

example@example.com

Relationship to Participant

Is this emergency contact aware that you (or your child) attends an LGBTQ+ program?

Other

Please tell us how you would like us to refer to you when talking to this contact

2nd Emergency Contact

First NameLast Name

Phone Number

Format: (000) 000-0000.

E-mail

example@example.com

Relationship to Participant

Is this emergency contact aware that you (or your child) attends an LGBTQ+ program?

Other

Please tell us how you would like us to refer to you when talking to this contact

3rd Emergency Contact

First NameLast Name

Phone Number

Format: (000) 000-0000.

E-mail

example@example.com

Relationship to Participant

Is this emergency contact aware that you (or your child) attends an LGBTQ+ program?

Other

Please tell us how you would like us to refer to you when talking to this contact

I agree with the following statements:

I have read and understand The Frederick Center’s Confidentiality Policy:

Attendees participating in The Frederick Center activities and events must adhere to our Confidentiality Agreement. Information from the meeting will NOT be shared:
●       with friends, family members, or coworkers,
●       on the internet, including social media sites, and
●       regarding names, conversations, or specific topics and discussions.

If a staff member is aware of a participant not following this agreement, they will report it to the Program Director, Executive Director, or a board member as soon as possible.

I understand that I may encounter confidential information while visiting The Frederick Center or attending The Frederick Center programming. As part of the condition of my participation in events with The Frederick Center, I hereby agree to maintain the confidentiality and privacy of other TFC clients, participants, or other attendees. I agree never to remove confidential information or material from The Frederick Center facility or events.

I understand that violation of this agreement may result in the termination of my participation in The Frederick Center programming, events, or sponsored activities, at the discretion of TFC staff and the Board of Directors.

In addition, The Frederick Center’s Youth Group facilitators follow therapist-patient confidentiality policies. All Youth Group meetings are confidential unless a facilitator is concerned for your safety and is required to report to a parent or guardian, to CPS, or to another agency.

Date

Signature