STUDENT/YOUTH Volunteer Registration: Saturday, October 29, 2022 Medication & Sharps Collection Proudly supporting the Drug Enforcement Administration's National Drug Take Back Day

If you are an Adult and are not registering a youth/student, please complete the survey at www.surveymonkey.com/r/Adults10-29-22. Thank you!

This registration MUST be completed by parents/adult and NOT youth/students:
HC DrugFree's medication and sharps collection is scheduled for Saturday, October 29 from 10 a.m. to 2 p.m. (with set up 9:15 a.m. and cleanup from 2:00 to 2:15 p.m.). Youth hold signs/arrows away from the collection site. Youth are NOT permitted to collect medication or sharps. Rain or shine, this is an outdoor event in the Wilde Lake Village Center parking lot. Based on CDC and County safety guidelines at the time of the event, participants may be expected to wear masks and socially distance. Please be sure youth bring masks with them.

Please register each participant through their own individual form. Thank you!!!

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* 1. Student's first name

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* 2. Student's last name

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* 3. Age of youth/student

18 or older (STOP! Complete ADULT registration if 18 or older.)

High school age

Middle school age

Other (please specify)

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* 4. To keep youth safe, we would like an adult to be with student volunteers. We encourage groups to have an adult chaperone with their youth. If no adult is available, we may decline your student's participation. Will you or an adult you trust be with your student?

Yes

Other (please specify)

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* 5. If yes above, name of adult.

I will supervise my own student

Other (please specify)

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* 6. Parent's/guardian's first name

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* 7. Parent's/guardian's last name

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* 8. Parent's email address

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* 9. Re-enter email address

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* 10. Youth/student's email address

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* 11. Re-enter email address

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* 12. Emergency phone number

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* 13. Re-enter phone number

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* 14. List EXACT time between 9:15 a.m. and 2:15 p.m. youth/student wants to be with us. Our preference is to have the same students remain from 9:15 to 2:15 to limit students coming/going. We may decline volunteers not needed or if the time options are not best for HC DrugFree. Feel free to add comments for us to consider.

All day - 9:15 to 2:15 (We encourage volunteers to bring lunch or snacks. Restaurants in plaza. HCDF hopes to provide some snacks/water.)

Morning only - 9:15 to noon

Afternoon only -noon to 2:00

Other (please specify exact time)

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* 15. Is youth/student willing to volunteer rain or shine? (Please be sure students dress for the weather.)

Yes

Other (please specify)

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* 16. Is youth/student willing/able to hold a sign

Yes

Other (please specify)

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* 17. If youth/student is not able to stand or prefers to sit, will you provide your own lawn chair? (We will not provide chairs.)

Yes

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* 18. Volunteers may be required to wear a mask and/or socially distance and must follow HC DrugFree's guidance and procedures based on CDC and County guidelines on October 29. Do you agree that you will explain this to your student and they will comply?

Yes

No (please specify)

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* 19. Volunteers previously at our medication collections or other events were given t-shirts and are expected to wear them and dress appropriately for the weather (rain or shine!). If it's cold, plan to layer UNDER the t-shirt so they can be seen. Does your student already have our shirt?

Yes

If no, what size shirt is needed in case we do provide more shirts:

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* 20. Questions or additional information for HC DrugFree

By submitting this registration and as the parent and/or legal guardian of this youth/student, I agree to this waiver(s):

I have read this waiver and knowing the facts, I, for myself and anyone entitled to act on my behalf, waive and release HC DrugFree and its employees, directors, officers, partners, agents, and sponsors from and against all claims, demands or causes of actions for accidents, personal injury, bodily injury, death, property damage or other injury or loss or damage of any kind, occurring from any cause arising from or related to or in connection with named participant’s involvement in the event named above.

Further, I grant permission to all of the foregoing to use named participant’s photographs, audio and audio visual recordings or any other record of this event for any legitimate purpose.

I understand that it is my responsibility to IMMEDIATELY report any injury or concerns to HC DrugFree’s Executive Director or Board Member present at this event.

I agree to discuss the following with my youth/student: the importance of wearing a mask throughout this event, social distancing even outdoors, and proper hand sanitizing.