Microsoft word - medical information and consent form.doc
Date _______________ WOW Week:________________ Name_______________________________________ Church/Group Name_______________________ Parent/Guardian_______________________________________________________________________ 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
II. EMERGENCY CONTACTS 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 ________________________ 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 #_______________________________________________________________________ Group #_______________________________________________________________________ Please include a copy of your Medical Insurance Card if possible.
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Demokratipolitik Studieförbundet Näringsliv och Samhälle Inledning Vid årsskiftet lägger regeringen fram sin stora demokratiproposition. Därmed får riksdagen tillfälle att begrunda den svenska folkstyrelsensframtid. De beslut som då kommer att fattas, eller inte fattas, kommeratt få stor betydelse för svensk samhällsutveckling. Denna skrift vill ge ett bidrag till debatten inf
