SHE IS US UNITED INC. Healthcare Youth Volunteer Consent Form
Please complete this form to enroll your child as a volunteer and provide necessary information for participation.
Minor Volunteer Information
First Name
*
Last Name
*
Date of Birth
*
-
Month
-
Day
Year
Date
Age
*
City / ZIP Code
School Name and Grade Level
Parent/Guardian Information
Parent/Guardian Full Name
*
First Name
Middle Name
Last Name
Relationship to Minor
*
Primary Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
*
example@example.com
Best way to reach you
*
Phone Call
Text
Email
Emergency Contact
Emergency Contact Full Name
*
First Name
Last Name
Relationship to Minor
*
Emergency Contact Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Is this the same as parent/guardian?
*
Yes
No
Medical Information
Medical conditions we should be aware of
Allergies
Medications currently taken that may affect participation
Consent for Communication
Consent for your child to receive group text messages for program updates and scheduling
*
Yes
No
Consent for photos and video of your child to be taken for program and social media use
*
Yes
No
Consent for your child’s information to be securely stored for program coordination purposes
*
Yes
No
Availability
What days is your child generally available?
*
Weekday Daytime
Weekday Evenings
Weekend Daytime
Weekend Evenings
Flexible / As Needed
Are there any specific days or times your child is not available?
Program Participation
2026 Participation Statement
Attend virtual program meetings
*
Yes
No
Attend in-person sessions and workshops
*
Yes
No
Participate in health certification preparation sessions
*
Yes
No
Participate in community health events and outreach activities hosted by She Is Us United Inc.
*
Yes
No
Acknowledgements
*
I understand all in-person activities will be supervised by She Is Us United Inc. program leadership
I understand advance notice of no less than two weeks will be given for all in-person events
Mentorship Interest
Is the child interested in being paired with a healthcare professional mentor?
*
Yes
No
Not sure yet
Which healthcare areas are of interest for mentorship?
Clinical Care
Public Health
Behavioral Health
Research and Biomedical Sciences
Healthcare Administration
Not sure yet
Referrals
Do you know anyone else who may be interested in joining the program?
Yes
No
Referral Name
Referral Email
example@example.com
Referral Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Liability and Transportation
Acknowledge transportation responsibility
*
I understand that transportation to and from all activities is my responsibility as the parent or guardian unless otherwise communicated in writing
Other
Acknowledge liability release
*
I release She Is Us United Inc. from liability for any injury sustained during volunteer activities conducted in good faith
Other
Signatures and Date
Parent/Guardian Full Name
*
First Name
Middle Name
Last Name
Parent/Guardian Signature
*
Date
*
-
Month
-
Day
Year
Date
Youth Volunteer Full Name
*
First Name
Middle Name
Last Name
Youth Volunteer Signature
*
Date
*
-
Month
-
Day
Year
Date
Submit
Submit
Should be Empty: