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Participant Information Form for the Luepke Senior Center

Include city, state and zip code
Please include name, phone number and relationship for all contacts
Participant's Medical Information:

Please note: Vancouver Parks & Recreation Department employees and volunteers cannot administer medication. If you need medication and/or extra staff assistance during program hours please contact the coordinator for the appropriate forms and procedures.

Authorization for Medical Treatment

I/We hereby freely and voluntarily authorize the City of Vancouver, Vancouver Parks and Recreation Department to request and obtain emergency medical care at my/our expense from such medical care provider as is immediately available in any situation which department employees or agents determine such care is required.

Type in name for electronic signature
(If you're a human, don't change the following field)
Your first name.
(If you're a human, don't change the following field)
Your first name.