BACKGROUND INFORMATION (only required for participants 16 years and older) Do you use illegal drugs? Yes No Have you ever been convicted of a criminal offense? Yes No Have you ever been charged with and/or convicted of neglect, abuse or assault? Yes No Has your driver's license ever been suspended or revoked in any jurisdiction? Yes No If you any of the questions, please provide details: answered “yes” to HEALTH INFORMATION **Health information is collected in case of emergency. Each participant is responsible for determining if the participant is physically able to participate. Please mark if you have any of the following conditions and provide details: Special Dietary Needs: Allergies: Assistive or Implantable Devices: High Blood Pressure: Heart Condition: Asthma or Respiratory Condition: Mental Health Condition: Epilepsy or Seizure Disorder: Neurological Condition: Diabetes: Sickle Cell Anemia/Trait: Chronic Infection: Missing Organ (e.g., spleen, kidney): Other Health Conditions: Please list any medications, vitamins, or dietary supplements below: Medication Name Dosage Times per Day Class A Volunteers and Unified Partners who are 18 years of age and older are required to complete the online Protective Behaviors training, unless they are a current high school student. Access the Protective Behaviors training at . CLASS A VOLUNTEER & UNIFIED PARTNER REGISTRATION I agree to the following
BACKGROUND INFORMATION (only required for participants 16 years and older) Do you use illegal drugs? Yes No Have you ever been convicted of a criminal offense? Yes No Have you ever been charged with and/or convicted of neglect, abuse or assault? Yes No Has your driver's license ever been suspended or revoked in any jurisdiction? Yes No If you answered “yes” to any of the questions, please provide details: HEALTH INFORMATION **Health information is collected in case of emergency. Each participant is responsible for determining if the participant is physically able to participate. Please mark if you have any of the following conditions and provide details: Special Dietary Needs: Allergies: Assistive or Implantable Devices: High Blood Pressure: Heart Condition: Asthma or Respiratory Condition: Mental Health Condition: Epilepsy or Seizure Disorder: Neurological Condition: Diabetes: Sickle Cell Anemia/Trait: Chronic Infection: Missing Organ (e.g., spleen, kidney): Other Health Conditions: Please list any medications, vitamins, or dietary supplements below: Medication Name Dosage Times per Day Class A Volunteers and Unified Partners who are 18 years of age and older are required to complete the online Protective Behaviors training, unless they are a current high school student. Access the Protective Behaviors training at . CLASS A VOLUNTEER & UNIFIED PARTNER REGISTRATION I agree to the following
2_FORM_D_Class_A_Volunteer__Unified_Partner_Registration_2018-19.docx