Youth Services Network

Emergency Form
Parent/Guardian 1:*

First NameLast Name
Relationship to Youth:*
Parent/Guardian Phone Number:*
Please enter a valid phone number.
Parent/Guardian Email:*
example@example.com
Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent/Guardian 2:

First NameLast Name
Relationship to youth:
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number:
Please enter a valid phone number.
Email:
example@example.com
Designated Youth Pick Up - Must put a person other than parent or guardian
Name:*

First NameLast Name
Gender:*
Relationship to Child:*
Phone Number:*
Please enter a valid phone number.

Allergies and Administration of Medicines
Asthmatic:*

YesNo
Medical Condition:
Food Allergies:*

YesNo
Please list down below:
Allergic reactions, signs or symptoms to look for:
All medications, prescription and over the counter, must be provided to the City of Antioch staff in their original packaging, with your child's full name written on the container. Remember to provide medication cups, spoons, or other instruments for the medication's administration. The medication dosage must be completed below in the INSTRUCTION section. If the additional instructions are required, please attatch another sheet.
Instructions: Parents/Guardians- Please write specific step-by-step instructions for staff to follow in the event your child has an allergic reaction or displays symptoms of a medical condition. You must confirm these steps with your child's physician or health care provider. By providing these instructions, you are consenting to staff's ASSISTANCE with medical treatment of your child.

For example:

1.Administer Epi-Pen
2. Administer 2 teaspoons of liquid Benadryl
3.Call 911
4.Call parents at---
Please list below:

Medical Authorization
Date:*

MonthDayYear
Date
Parent/Guardian Signature:*

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Reminders:

Participants are responsible for arriving at the program with all necessary medications, supplies, pumps, back-up medications and any other equipment necessary for the participant to safely self administer their medications.
Medical monitoring of blood sugar levels must be done by parent or guardians prior to attending the program each day, to ensure that they are within their target range.
Staff will not be responsible for identifying symptoms of hyperglycemia or hypoglycemia, but can assist the participant in checking blood sugar levels with proper training provided by parents or guardians.
Parents/guardians are responsible for providing all necessary information regarding dietary restrictions, food allergies or special diet considerations to staff.
Participants and parents/guardians shall be advised and reminded that it is the participants responsibility to administer the medication and that staff will only assist as needed. Staff will not give scheduled injections.
It is the responsibility of the parent/guardian to pick up any medications that remains at the conclusion program. Any medication not picked up with be disposed of in a safe manner.

Media Release
Date:*

MonthDayYear
Date
Parent/Guardian Signature:*

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Printed Name:*

Step 2: Required Documents

Note: This application does not automatically qualify you for the program. Staff will reach out once the application is turned in and completed.
Please provide/complete all documents listed below:
- Recent Report Card/Progress Report
- 1-9 Documents(ONLY IF YOU ARE 14 0R 15 YEARS OLD).
- W-9 Form(ONLY IF YOU ARE 14 0R 15 YEARS OLD).
- Yoch Form-Signed
- Yoch Contract-Signed
1. Most recent report card/progress report: Needs a B or higher in Math or English. *

Cancelof
2. 1-9 Documents (Please refer to the document for a list of eligible 1-9 Documents). *

Cancelof
Yoch Contract Signature:12-13 year olds. Sign N/A if it doesn't apply to you. *
Yoch Contract Signature:14-15 year olds. Sign N/A if it doesn't apply to you.
Yoch Form Signature:
Should be Empty: