Adult Mission Volunteer Health Information and Emergency Contact

Name

Date of Birth

Address

Home Phone

Cell Phone

Family Doctor

Doctor Phone

Health Insurance Carrier

Contract Number

Insurance Phone

Group Number

Insurance Phone

Date of last Tetanus shot

Are you taking any medications at present?

Yes No

If “Yes”, list each medication, dose, freq.

Do you have any allergies:

Yes No

If “Yes”, list allergy and reaction.

Are any medications or treatments helpful for allergy?

Do you have asthma? If Yes, MUST have inhaler on the trip.

Yes No

Do you have diabetes?

Yes No

If “Yes”, what is your treatment?_

Please describe any health conditions Trip leader should be aware: (pacemaker, lifting restrictions, diabetic, heart ailments, rare blood type, recent injuries/surgeries, etc.)

Note: It is each participant’s responsibility to bring needed / appropriate medications (i.e. EpiPens, insulin, inhalers and prescription medications) with you to the site.
First Presbyterian Church of Saline cannot be responsible for these medications.

Please list who could be contacted on your behalf in case of emergency:

Emergency Contact

Emergency Contact Address

Relationship to volunteer

EC Home Phone

EC Cell Phone

Authorization

I have provided this health information with knowledge of the conditions and activities contemplated during this mission trip. I have listed on this form all physical or emotional disabilities which would impair my participation. I am taking only the medication listed on this form and have no allergies known to me except as noted.

In the event of illness or injury, I authorize the physician and/or hospital to undertake such treatment of and perform such services (including surgical service) as are reasonably indicated by the circumstances.

Signature

Date

Description

Please complete the form and click submit. The information will be kept in the strictest confidence. This is standard, but critical information for First Presbyterian Church of Saline to be able to protect you, your family and the ministry to the greatest extent possible. We want to make sure that if an emergency occurs, the correct knowledge and preparation is in place to properly care for you.

Adult Mission Volunteer Health Information and Emergency Contact

Description

Please Fix the Following