Volunteer Medical Form - Youth Challenge

YOUTH CHALLENGE VOLUNTEER MEDICAL INFORMATION

This information is for official and medical confidential use only and will not be released to unauthorized persons.

First Name *

Middle Initial

Last Name *

Gender *

Male

Female

Other / Gender nonconforming

If \"other\" please specify

Street Address *

City *

Zip code *

County *

Home Phone *

Cell Phone *

Volunteer Email *

Date of Birth *

Parent (#1) First Name *

Parent (#1) Last Name *

Parent (#1) Home Phone *

Parent (#1) Cell Phone *

Parent (#1) Email *

Parent (#1) Place of Employment

Parent (#1) Work Phone

Parent (#2) First Name

Parent (#2) Last Name

Parent (#2) Address--if different than above

Parent (#2) Home Phone

Parent (#2) Cell Phone

Parent (#2) Email

Parent (#2) Place of Employment

Parent (#2) Work Phone

In case parents or guardians cannot be reached in an emergency...

Must be different than parents/guardians listed above.

Emergency Contact Name *

Relationship *

Emergency Contact Phone *

Medications *

Are there any medications or treatments that will be required while you are volunteering?

Allergies

Please list all allergies--including seasonal, insect bites/stings, etc.--that you may have.

Physical Conditions *

Please list any physical conditions that you have (back pain, heart condition, physical disability, visual impairment, etc.). Please email a separate sheet to YC with further details if necessary.

Preferred Physician: Name & Phone Number *

Preferred Dentist: Name & Phone Number *

Preferred Hospital *

Insurance Provider & Policy Number *

By typing my name below, I hereby certify that the information included herein is complete and accurate to the best of my knowledge.

If over 18, sign below. If under 18, parent/guardian signs below.

Electronic Signature of Parent/Guardian (or volunteer if over 18) *

Today\'s Date *

IN CASE OF EMERGENCY, I hereby grant my consent to the following action.

CHOOSE ONE OF THE FOLLOWING

By clicking below, I hereby grant my consent to transfer me or my child to: *

(YC will also call parent/guardian or emergency contact and follow instructions of the attending physician.)

By writing below, I DO NOT give my consent for emergency medical treatment of me or my child. In the event of illness or injury requiring emergency treatment, TAKE NO ACTION and call me or the emergency contact listed above.

Please list alternative procedure.

Electronic signature of parent/guardian (or volunteer if over 18) *

WILL BE SENT TO YOU IN A SEPARATE EMAIL TO COMPLETE AND RETURN

Today\'s Date *