Thornton Parks, Recreation, and Community Programs
Youth and Teen Volunteer Corps

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Personal Information

Name

Address

Primera Línea de Domicilio

Segunda Línea de Domicilio

Ciudad

Estado

Código Postal

Phone Number

Date of Birth

School Attended

Emergency Contact

Emergency Contact Name

Relationship to Emergency Contact

Emergency Contact Phone Number

Emergency Contact Email

Do you have any medical condition(s) that would limit your ability to perform your duties as a volunteer?

Do you have reliable transportation to and from the Thornton Community Center located at 2211 Eppinger Boulevard?

Sí No

Hobbies and Interests

Are you doing this program for documented community service hours?

Sí No

References

First Reference

Reference Name

Reference Phone Number

Refererence Relationship

Second Reference

Second Reference Name

Second Reference Phone Number

Second Refererence Relationship

Third Reference

Third Reference Name

Third Reference Phone Number

Third Refererence Relationship

Applicant Signature -- Type in Full Name

Additional Emergency Contacts

In the event of an emergency, staff will make every effort to contact the Emergency Contact listed above on this form.

Alternate Emergency Contact

Alternate Emergency Contact Name

Alternate Emergency Contact Relationship

Alternate Emergency Contact Phone Number

Alternate Emergency Contact Address

Primera Línea de Domicilio

Segunda Línea de Domicilio

Ciudad

Estado

Código Postal

Second Alternate Emergency Contact

Second Alternate Emergency Contact Name

Second Alternate Emergency Contact Relationship

Second Alternate Emergency Contact Phone Number

Second Alternate Emergency Contact Address

Primera Línea de Domicilio

Segunda Línea de Domicilio

Ciudad

Estado

Código Postal

Medical Information

Hospital of Choice

Preferred Hospital Address

Primera Línea de Domicilio

Segunda Línea de Domicilio

Ciudad

Estado

Código Postal

Any Allergies or Helath Problems we need to be aware of?

Special Instructions

Emergency Medical Authorization

I, , hereby give my permission to the City of Thornton to call a doctor for medical or surgical care for my child, , should an emergency situation arise. I also authorize Medical Personnel to treat my child once they arrive.

It is understood that a conscious effort will be made to locate me or my spouse before any action will be taken, but if it is not possible to locate us, this expense will be accepted by us.

Parent or Guardian Signature -- Type in Full Name

Date

By typing in your signature above, you hereby swear and affirm the information you have provided is true and accurate to the best of your knowledge.

Thornton Parks, Recreation, and Community Programs Youth and Teen Volunteer Corps

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Thornton Parks, Recreation, and Community Programs
Youth and Teen Volunteer Corps