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Microsoft word - medical information and consent form.doc
_______________________________________ Church/Group Name
_ Female Social Security Number
__________________________________ Personal Physician
Physician’s Group or Practice
____________________________________________________ I. HEALTH EXAM To be filled out by Physician. (
May substitute with most recent physical).
To Licensed Medical Practitioner:
The minor individual named above desires to participate as a Volunteer for WOW (Win Our World Inc and
all mission partners) and engage in the activities related to being a Volunteer. The Volunteer understands
that the activities may become physically stressful and or dangerous and include cleaning, building or
construction work, working with children and the elderly, being transported in vehicles to and from work
site locations and related group activities, and includes consuming food and living in accommodations set
up by the Win Our World Inc Summer ministry program. Please indicate:
____ Approved for participation in all activities
____ Specify any exceptions:
_____ Recommendations (explain any restrictions or liabilities): Printed Name:
M.D./ D.O./ D.C./P.A./R.N.P.
Licensed Medication Practitioner Circle One
II. EMERGENCY CONTACTS
If I have a medical emergency during my WOW Week, please contact the following family member: Name
________________________ Primary Phone
_________________________ Secondary Phone
______________________________ In case the above person is not available, please contact the following:
_____________________ Other Phone
_____________________ Other Phone
________________________ III. AUTHORIZATION TO OBTAIN MEDICAL TREATMENT FOR A MINOR
As parent/legal guardian of _________________________________________________, a minor, I do hereby
authorize and give permission to the WOW medical volunteer, or any adult chaperone designated by Win Our World
Inc, to seek and obtain any medical services that in their judgment my child may need while participating in WOW. It
is my understanding that I will be contacted as soon as possible, but not necessarily prior to emergency treatment that
might be medically required in the opinion of the medical care provider.
I further understand and agree that I will be responsible for any such incurred medical costs.
________________________________________________________________ _____________________________ Signature of parent/guardian
IV. NON EMERGENCY MEDICAL TREATMENT
My initials below indicate that I agree that my child may receive
the following non-emergency medical treatment from
any adult affiliated with Win Our World Inc, as deemed appropriate by the Executive Director or designated appointee.
_____ Acetminophen (e.g. Tylenol)
_____ Cough lozenges (e.g. Halls Cough Drops)
_____ Cough medicine (non-narcotic, e.g. Delsym)
_____ Anti-diarrhea medication (e.g. Imodium)
_____ Basic, non-invasive, First Aid (e.g. disinfecting
_____ Sore throat spray (e.g. Chloraseptic)
cream, topical ointment, sunburn lotion, etc.)
Please describe known allergies: ____________________________________________________________________
Please include other important information: ____________________________________________________________
V. INSURANCE INFORMATION
Medical Insurance Company
______________________________________________________ Policy #
Please include a copy of your Medical Insurance Card if possible.
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