name_________________________________ birth date___________ age______
address______________________________________________________________
_______________________________ state___________ zip code____________
health insurance company_____________________________________________
policy number__________________ medical record number________________
insurance company phone number to inform of accident_________________
In case of emergency whom shall we notify?
name____________________________________ relationship________________
home phone(______)________________ work phone(______)________________
Describe physical or mental conditions that may affect your service
such as allergies, asthma, diabetes, and prescription drugs you take
regularly. Be sure to note any allergies you have to medications:
_____________________________________________________________________
_____________________________________________________________________
I hereby release Quaker Workcamps International, its
Board of Directors and staff
of liability for any injuries I may sustain as a participant in this workcamp.
signed______________________________________ date____________________
I, the parent/guardian of______________________________________do
hereby consent
to any x-ray examination, anesthetic, medical/surgical diagnosis or treatment,
or
hospital services that may be rendered under the general or specific instructions
of the QWI Director, Project Director, or On-Site Coordinator.
I hereby release Quaker Workcamps International, its
Board of Directors and staff
of liability for any injuries that may be sustained by my child as a participant
in this workcamp.
signed______________________________________ date____________________
Instructions | page 1 | page 2 | page 3 | page 4 | page 5