Healthcare forms

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Emergency medical form for adu... ADULT EMERGENCY CONTACT AND MEDICAL FORM The information requested on this page is confidential and for emergency use only. In the event of an emergency this information will be used by program staff and emergency personnel. Please be honest when completing this form. SECTION 1. BASIC CONTACT INFORMATION Adult s Last Name Adult s Middle Name Home Address City Telephone 1 State Zip Code Date of Birth IN CASE OF EMERGENCY CONTACT Name Relationship Street Address ADULT S PHYSICIAN Phone SECTION 2. BASIC CONTACT INFORMATION Adult s Last Name Adult s Middle Name Home Address City Telephone 1 State Zip Code Date of Birth IN CASE OF EMERGENCY CONTACT Name Relationship Street Address ADULT S PHYSICIAN Phone SECTION 2. INSURANCE INFORMATION Please attach a photocopy of the policy holder s insurance card as proof of insurance. In the event of an emergency this information will be used by program staff and emergency personnel* Please be honest when completing this form* SECTION 1. INSURANCE INFORMATION Please attach a photocopy of the policy holder s insurance card as proof of insurance. Insurance Carrier Group or Policy Address for Claims Policy Holder s Name SECTION 3. HEALTH INFORMATION Are you allergic to anything No* Yes Please list all allergies. Are you taking any medication Do you have any medical/mobility/mental health concerns of which we should be aware should be known to program staff and medical personnel* If I am unable to give consent in the event of an emergency I hereby give permission to medical personnel to administer emergency medical treatment. Signature Print Name Date Participant Liability and Photo Release Form I hereby release indemnify and hold harmless Warren Wilson College the Exploring Joara Foundation Tulane University University of Michigan Western Piedmont Community College and their respective officers directors employees agents contractors subcontractors representatives successors and assigns and all persons conducting directly or indirectly the activities surrounding my involvement as a program participant from any and all claims rights demands actions causes of action expenses and damages which I or my heirs personal representative successors assigns or anyone claiming by through or under me ever had now have or may have against the parties identified above arising from any injury act or omission relating in the way to my participation as a program participant. I understand that I will not be entitled to and will not receive Worker s Compensations benefits or other similar payments from Warren Wilson College the Exploring Joara Foundation Tulane University University of Michigan or Western Piedmont Community College under the law of the State of North Carolina in the event that I am injured* I hereby provide consent to these institutions to copyright publish use sell or assign any and all photographic portraits or pictures television spots movie films videotapes and/or sound records or any part thereof that they may take or make of me during my time as a program participant in which I may be included in whole or in part whether separate from or in conjunction with illustrative or written manner story or news item motion pictures television or radio spots or for publicity advertising or any other lawful purpose whatsoever in and/or approve the finished product or the advertising copy that may be used in connection therewith or the use to which it may be applied* I hereby waive all claims for compensation of such use or for damages.

Student medical form DOCUMENTATION FOR THE 2017-2018 SEASON FLU VACCINE IS REQUIRED FOR ... STUDENT MEDICAL FORM, OR USE A SEPARATE FORM. RETURN ...

New student emergency medical... STUDENT EMERGENCY MEDICAL FORM (Please print) STUDENTS NAME: SCHOOL YEAR DATE OF BIRTH PRESENT GRADE STUDENTS ADDRESS: PHONE # Purpose: To authorize the emergency treatment for the child who becomes

Medical form winston salem das... MEDICAL FORM WINSTONSALEM DASH YOUTH BASEBALL ACADEMY MEDICAL HISTORY, TREATMENT PERMISSION AND RELEASE Note: This form is required prior to participation in The WinstonSalem Dash Youth Baseball Academy.

Cuny baruch medical form One Bernard Baruch Way Box H-0880 New York, NY 10010-5585 Tel: 646-312-2050 Fax: 646-312-2051 http://www.baruch.cuny.edu caps baruch.cuny.edu INTERNATIONAL STUDENT SERVICE CENTER CONFIDENTIAL DECLARATION

Summit bechtel medical form Participant s Printed Name: Council & Unit: Arrival Date: MEDICAL CONSENT FORM PARTICIPANT ACKNOWLEDGEMENT In case of an emergency, I understand that every effort will be made to contact the individual

High adventure activity medica... High Adventure Activity Medical Form Attach to Participant s Health and Medical Form (Valid for 12 months from the date signed by the medical professional) Participant Name DOB: / / Age Emergency

Dominion power medical form Dear Customer, If you have a serious medical condition, please print a copy of this form and contact us at 1-866DOM-HELP (1-866-366-4357) in order to apply a 10-day extension to your active account. Individuals

Duke medical form BARGAINING UNIT RETIREE MEDICAL CHANGE FORM Return the completed form within 30 days of the qualifying event to: Progress Energy Employee Service Center PEB 16 ESC, P.O. Box 1551, Raleigh, NC 27602-1551.

Tlc medical form Licensing and Standards Division 32-02 Queens Boulevard Long Island City, NY 11101-2324 1893 Richmond Terrace Staten Island, NY 10302 +1 212 227 6324 tel, www.nyc.gov/tlc MEDICAL CERTIFICATION FORM

Dental patient medical form Dental 617 Riverside Avenue Burlington, VT 05401 Medical: (802) 864-6309 Staff Initials: Patient Medical History Form Fax: (802) 652-1056 Dental: (802) 652-1050 www.chcb.org Patient Name: Date of

Cub scout medical form a b 201... Full name: DOB: Allergies: Emergency contact No.: Annual BSA Health and Medical Record Part A GENERAL INFORMATION High-adventure base participants: Expedition/crew No.: or staff position: Female Name

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