YC19: Camp Volunteer Adult Medical form

The following information is required for all adult participants. Information is confidential and will be made available only to those adults who are directly responsible for the participant’s care. For their safety and well-being, no participant will be allowed to be part of the event without a completed and signed Medical Form.

1. VOLUNTEER STAFF INFORMATION:

*First Name
*Last Name
*Address 1
*City
*State
*Zip
*Phone
*Email
*Birth Date:
*Gender:
Male
Female

2. IN CASE OF AN EMERGENCY, PLEASE CONTACT:

*Name:
*Relationship:
*Phone:

please include area code

3. INSURANCE INFORMATION:

*Family Physician:
*Phone:

please include area code

*Insurance Carrier/Plan Name:
*Policy ID#
Insurance Carrier's Address, City, State:

4. MEDICAL HISTORY:

*Date of last tetanus shot:
*Date of last physical exam:
Please list any allergies (food, medicine, etc.):
*Taking any medications:
Yes
No
Please list:
*Are you under the care of a physician?:
Yes
No
Please explain:
*Any medical conditions that we should be aware of:
Yes
No
Please explain:
*Vegetarian:
Yes
No
Special Dietary needs:
RELEASE STATEMENT:

I, the undersigned, do hereby authorize the adult leaders acting on behalf of the California-Nevada Annual Conference The United Methodist Church, as agent, and working with other nonprofit agencies to consent to any examination, x-ray, anesthetic, medical or surgical diagnosis or treatment and hospital care which is deemed advisable by, and is rendered at the office of said physician or at said hospital. It is understood that this authorization is given in advance of any specific diagnosis, treatment, or hospital care being required but is given to provide authority and power on the part of our aforesaid agent(s), especially in case of emergency, to give specific consent to any such diagnosis, treatment, or hospital care which the aforementioned physician in the exercise of his or her judgment may deem advisable. I agree to pay for any medical, dental, surgical, or hospital diagnosis, treatment, or care rendered to me.

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