Microsoft word - medical information and consent form.doc

Date _______________
WOW Week:________________

_______________________________________ Church/Group Name_______________________
DOB _______________ Age _______________ Sex: _ Male _ Female
Social Security Number __________________________________
Personal Physician _________________________________ Telephone (____) ____________________

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:_____________________________________________________
Signed: _____________________________________ Date: __________________
M.D./ D.O./ D.C./P.A./R.N.P.
Licensed Medication Practitioner Circle One

If I have a medical emergency during my WOW Week, please contact the following family member:
Name___________________________________________ Relationship: ________________________
Primary Phone _________________________ Secondary Phone ______________________________
In case the above person is not available, please contact the following:

Name________________________ Phone _____________________ Other Phone ________________________
Name________________________ Phone _____________________ Other Phone ________________________

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

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: ____________________________________________________________


Medical Insurance Company ______________________________________________________
Policy #_______________________________________________________________________

Group #

Please include a copy of your Medical Insurance Card if possible.


Microsoft word - lyrica.doc

How Does LYRICA Help? LYRICA works by attaching to a part of the over-firing nerve cells. This is thought to help to reduce the pain signals that cause the symptoms of diabetic nerve pain. It can also be used “off label: that is for similar types of pain problems that the FDA has not examined or approved it for. In any case, this may reduce the nerve pain that can prevent the enjoyment of


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