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Bsa medical form Bsajamboree. org 304-250-6750 For frequently asked questions about this Annual Health and Medical Record see Scouting Safely online at http //www. Si el madre o tutor. Date/Fecha Participant s signature/Firma del participante Second parent/guardian signature/Firma del otro padre o tutor if required for example CA/si se requiere por ejemplo en CA This Annual Health and Medical Record is valid for 12 calendar months. Annual Health and Medical Record Registro M dico y de Salud Anual Valid for 12 calendar months V lido por 12 meses calendario Policy on Use of the Annual Health and Medical Record Pol tica para el uso del Registro M dico y de Salud Anual In order to provide better care for its members and to assist them in better understanding their own physical capabilities the Boy Scouts of America recommends that everyone who participates in a Scouting event have an annual medical evaluation by a certified and licensed health-care provider a physician MD or DO nurse practitioner or physician assistant. To be better prepared each participant must complete the following before attending any high-adventure base or La participaci n en cualquiera de las bases de aventura extrema de BSA o en cualquier actividad de aventura extrema en terrenos campestres aislados puede ser f sica mental y emocionalmente agotadora. Para estar mejor preparado cada participante debe completar lo siguiente antes de acudir a cualquier base de aventura extrema o de participar en cualquier actividad de aventura extrema en terrenos campestres aislados Fill in parts A and B of the Annual Health and Medical Record. Providing your medical information on this four-part form will help ensure you meet the minimum standards for participation in various activities. Note that unit leaders must always protect the privacy of unit participants by protecting their medical information* A fin de proporcionar una mejor atenci n para sus miembros y para ayudarles a entender mejor sus propias capacidades f sicas Boy Scouts of America recomienda que todos aquellos que participen en un evento Scouting se sometan a un examen m dico anual realizado por un prestador de servicios de salud certificado y con licencia un m dico Doctor en medicina o Doctor en osteopat a enfermera profesional o asistente m dico. Proporcionar su informaci n m dica en este formulario de cuatro partes ayudar a asegurar que usted cumple con los est ndares m nimos de participaci n en varias actividades. Tome en cuenta que los l deres de unidad siempre deben proteger la privacidad de los participantes al salvaguardar su informaci n m dica* Parts A and B are to be completed at least annually by guardian informed consent and release agreement and talent release statement is to be completed by the participant and parents/guardians. Attach a copy of both sides of your insurance card. Part C is the pre-participation physical exam that is required for participants in any event that exceeds 72 consecutive hours for all high-adventure base participants or when the nature of the activity is strenuous and demanding.

Contoh medical form FORMULA PELAYANAN MEDIA / MEDICAL SERVICES FORM Denis Claim (Berg Tanya X) / Claim type (please give X remarks) : Rabat Japan / Outpatient Gigi / Dental Rabat Snap & Pembedahan / Inpatient & Surgical

Medical form for teachers Outdoor School Medical Information Form Valid 2017 For Students & Visiting Teacher (VT) to fill in This information is intended to assist Outdoor School in case of any medical emergency with your

Employee medical form pdf 368. 2450 Fax 216. 368. 8530 healthservice case. edu Health Service Occupational Health Medical History Employee Information students. case. edu/health Name Last First Middle/Maiden Home Address Street City Zip Code Home Telephone Date of Birth Male Female MM/DD/YYYY Position Department Supervisor Campus Telephone Email Address In Emergency Notify Telephone Address Have you ever worked at Case Western Reserve University Has your name changed Yes No Please give previous name Medical History Current physicians or clinics attended Allergy History Medicine/Drugs Foods Insects etc. Medication/Drugs taken regularly Have you had or do you now have Please check all that apply Seizures Bone or joint pain High blood pressure Loss of eye sight Bleeding problems Breathing problems Parkinson s disease Heart disease Arthritis Cancer Amputation Tuberculosis Multiple sclerosis Muscular dystrophies Backache chronic Black out spells Blood clots Neurological problems Disability/Rehabilitation Diabetes Varicose veins Stroke Circulation problems Immune system disease Hepatitis/Jaundice Please list any other medical problems you may have Have you had any of the following Hernia Repair Type Date Orthopedic Surgery Cardiac Surgery Other Surgery Date of Immunization Tetanus booster Rubella Immunization Measles Immunization Rabies Immunization Rabies Titer Have you had Hepatitis B vaccine Do you smoke Do you exercise Approximate Date If yes what If yes How frequently For what length of time Explain Prior Work Environment Have you ever had an On the Job injury If Yes Date Place Carcinogens Asbestos Radio-active materials Radiation producing equipment If YES please indicate where Do you understand all of these questions Case Work Environment What are your duties Will you be Doing any lifting Working with chemicals What kind Working with patients Where Handling experimental animals Picking up biohazard waste for disposal I have completed this form and I certify that the information given is true. University Health Service Division of Student Affairs 10900 Euclid Avenue Cleveland Ohio 44106-4901 Phone 216. 368. 2450 Fax 216. 368. 8530 healthservice case. edu Health Service Occupational Health Medical History Employee Information students. case. edu/health Name Last First Middle/Maiden Home Address Street City Zip Code Home Telephone Date of Birth Male Female MM/DD/YYYY Position Department Supervisor Campus Telephone Email Address In Emergency Notify Telephone Address Have you ever worked at Case Western Reserve University Has your name changed Yes No Please give previous name Medical History Current physicians or clinics attended Allergy History Medicine/Drugs Foods Insects etc* Medication/Drugs taken regularly Have you had or do you now have Please check all that apply Seizures Bone or joint pain High blood pressure Loss of eye sight Bleeding problems Breathing problems Parkinson s disease Heart disease Arthritis Cancer Amputation Tuberculosis Multiple sclerosis Muscular dystrophies Backache chronic Black out spells Blood clots Neurological problems Disability/Rehabilitation Diabetes Varicose veins Stroke Circulation problems Immune system disease Hepatitis/Jaundice Please list any other medical problems you may have Have you had any of the following Hernia Repair Type Date Orthopedic Surgery Cardiac Surgery Other Surgery Date of Immunization Tetanus booster Rubella Immunization Measles Immunization Rabies Immunization Rabies Titer Have you had Hepatitis B vaccine Do you smoke Do you exercise Approximate Date If yes what If yes How frequently For what length of time Explain Prior Work Environment Have you ever had an On the Job injury If Yes Date Place Carcinogens Asbestos Radio-active materials Radiation producing equipment If YES please indicate where Do you understand all of these questions Case Work Environment What are your duties Will you be Doing any lifting Working with chemicals What kind Working with patients Where Handling experimental animals Picking up biohazard waste for disposal I have completed this form and I certify that the information given is true.

Mass rmv immediate threat medi... P.O. Box 55896 Boston, MA 02205-5896 www.mass.gov/massdot/rmv Request for Immediate Threat License Suspension / Revocation Please Mail Immediately or FAX to (857) 368-0013 TO: The Registry of Motor

New patient medical forms pdf NEW PATIENT HISTORY FORM NAME (Last, First, Middle) HOME PHONE AGE WORK PHONE BIRTHDATE OCCUPATION SEX MARITAL STATUS S EMERGENCY CONTACT? S PHONE PREVIOUS PHYSICIAN M W D IF MARRIED, SPOUSE? S NAME

Ntsa medical form FORM A DRIVING SCHOOLS REGISTRATION/ RENEWAL/ VARIATION CHECKLIST PART A. GENERAL INFORMATION Please fill in the necessary information. a) Name of driving school b) Postal address c) d) e) f) g)Physical

Firearm application medical fo... Republic of Guyana APPLICATION FOR JOINT FIREARM License (EXISTING License) INSTRUCTION: Please complete application in CAPITAL LETTERS. Failure to complete all sections will affect processing of

Medical form 11947292 SUN Downstate Medical Center Office of Financial Aid 450 Clarkson Avenue, Room 1-114 Brooklyn, NY 11203-2098 (718) 270-2488 Federal Work-Study Employment Request Form Supervisor's Name: (Please Print)

Standard form3107 2 Released 6/13/99. FERS Federal Employees Retirement System SPOUSE'S CONSENT TO SURVIVOR ELECTION Instructions: If you are married and you do not want a reduced annuity to provide a current spouse

Consent to exchange informatio... RCSC Form#3 CONSENT TO EXCHANGE INFORMATION-SWVTC RCSC I understand that different agencies provide different services and benefits. Each agency must have specific information in order to provide

Form 11 consent orders 2012 20... Application for Consent Orders Form 11 Please type or print clearly and mark X all boxes that apply. Attach extra pages if you need more space to answer any question/s. COURT USE ONLY Client ID Filed in Family Court of Western Australia File number Other specify Filed at Notice to the parties Each party to the application must sign an affidavit - for an applicant in accordance with Part I and for a respondent in accordance with Part K. The application must be filed promptly. The consent order may not be made if the application is not filed within 90 days of the date of the first affidavit see Parts I and K. Each copy of the draft consent order must be certified by the applicant or lawyer as a true copy. If an order or injunction is sought under Part VIIIAA or Part VIIIAB of the Family Law Act the third party must be named as a respondent to this application and must sign the draft consent order. The third party must also sign an affidavit in accordance with Part M of the form but is not required to complete any other Part. Part A About the parties APPLICANT What is your family name as used now RESPONDENT Given names Male Female What is your usual occupation What is your contact address address for service What is your contact address address for service in Australia If you give a lawyer s address the name of the law firm* include the name of the law firm* State Postcode Phone Fax DX Lawyer s code Email Please do not include email or fax addresses unless you are willing to receive documents from the Court and other parties in that way. Signature of applicant. Signature of respondent. When and in what country were you born DAY/MONTH/YEAR / COUNTRY Are you of Aboriginal and/or of Torres Strait Islander origin No Yes Aboriginal Torres Strait Islander Aboriginal and Torres Strait Islander You are not required to answer this question but it will greatly assist the Court if you do. The information sought is being collected to assist the Court in planning and delivering client services. It is possible that you may be contacted to participate in a review of a particular aspect of the Court s services although your right not to participate will be respected* The information you provide may be shared with researchers approved by the Court and may be included in publications in statistical form in a way that does not identify you. If there is more than one applicant or respondent attach an extra page with the details for Applicant 2 / Respondent 2 answering Items 1-5. A third party who will be bound by an order sought under Part VIIIAA or Part VIIIAB of the Family Law Act must be named as a respondent but need not complete any of this form except Part M. Part B About the relationship of the parties NOT APPLICABLE When did you begin living together DATE If married when and where did you get married TOWN/CITY When did you finally separate When and where did you get divorced Part C About other Court cases and orders IF YOU ARE SEEKING PARENTING ORDERS ANSWER ITEMS 10 TO 13.

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