YMCA Volunteer Application

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Welcome to the Volunteer Application for the YMCA of the Seven Council Fires (formerly known as the "Sioux YMCA"). If you are filling out this application before a representative from your group has reached out to one of our staff members, please email our Family Camp Director, Pete Stahlbrand, at pete@siouxymca.org to ensure that this is the correct form for your group.

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El. paštas *

PARTICIPANT INFORMATION

First and Last Name: *

What best describes you? *

Volunteer (or group member)

Group Leader/Facilitator

Kita:

Are you coming with a group? Insert group's name below.

Dates of Volunteering: (XX/XX/XXXX - XX/XX/XXXX) *

Pronouns (what's this? https://drive.google.com/file/d/1Mu1qjpoUwI5dm7GIjrfAZIrBnVxU7RxQ/view?usp=sharing): *

Date of Birth: *

YYYY

Gender Identity: *

Tribal Affiliation: (insert "none" if not applicable to you) *

Mailing Address: *

T-shirt Size: *

XXL

XXXL

EMERGENCY CONTACT INFORMATION

Primary Contact Name: *

Relationship to Participant: *

Phone Number: *

Mailing Address: *

Email Address: *

Secondary Contact Name:

Relationship to Participant:

Phone Number:

Mailing Address:

Email Address:

HEALTH INFORMATION

All information provided is private and confidential. If this does apply to you, leave the answer field blank.

Are you covered by medical/hospital insurance? *

Yes

If yes, indicate the insurance carrier information below. *

Description of Health History:

Allergies:

Dietary Restrictions:

Have you received a complete COVID-19 vaccination? (If no, we ask you test negative 48 hours before arrival, submit proof of test, and wear a mask in all indoor spaces) *

Yes

MEDICATIONS

Please list ALL medications (including over-the-counter or nonprescription drugs) taken routinely. Bring enough medications to last the duration of the volunteer experience. Keep them in the original bottle/packaging that identifies the name of the participant, the name of the medication, the dosage, and the frequency of administration.

Medication Names, Dosage, and Time Taken Each Day (separate different medications with a ";"):

RELEASE

Check each statement to show you have read and agree.

I certify that the participant is capable of safe participation in all volunteer activities. If the participant has any conditions that would limit participation, they will show written proof of physician’s authorizations to participate in activities.

I give permission for the participant’s photo, video image and/or name to be used in promotional literature including, but not limited to: brochures, websites, links, pamphlets, and newspaper.

I give permission for the Sioux YMCA staff to provide or obtain medical attention for the volunteer in the event of sickness or injury and I understand accident insurance is not included in volunteer fees. Should a participant require medical attention, prescription, or hospital care during this trip, all expenses will be the responsibility of the participant.

In the event that a parent/guardian (if necessary) cannot be reached in an emergency, I hereby give permission to the YMCA Staff to recommend treatment at IHS, the Family Health Center in Eagle Butte.

I understand, accept and assume full responsibility for all risk of bodily injury, accident, illness or death involved in this volunteer immersion experience. I agree to indemnify the Sioux YMCA staff, volunteers, Board of Directors, and all leaders and any instructors from any and all injury, which might occur during participation of volunteering.

Possession or use of tobacco, alcohol, illegal drugs or weapons are prohibited. We reserve the right to search property at any time without notice. If suspicious arises that a weapon or illegal substance is present on our facilities, law enforcement will be notified. Violators will be dismissed without refund.

We promote Honesty, Caring, Respect and Responsibility. Should my behavior affect our work or the safety of other volunteers, we reserve the right to dismiss without refund those responsible.

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