2. First and Last Name:
3. D.O.B.:
5. Home Address:
7. City:
8. State:
9. Zip:
11. Telephone (home):
12. (work):
14. Emergency Contact Person:
15. Telephone:
17. To assist in your job or task placement, please check all that apply (if you have had or are now experiencing):

    1. Poison Ivy Allergy
    2. Fainting/Blackouts
    3. Now Pregnant
    4. Allergic to Bee Stings
    5. Heart Trouble
    6. HIV Positive
    7. Other Allergies
    8. Heat Stroke
    9. Hemophilia
    10. Diabetes
    11. Asthma
    12. Cancer
    13. Frostbite
    14. Epilepsy
    15. Back Injury
19. Other Disability
21. Do you have medical restrictions limiting the work you can do?

    1. Yes
    2. No
22. If yes, please explain:
24. Are you currently under a doctor's orders regarding work?

    1. Yes
    2. No
25. If yes, please explain:
27. Physician:
28. Clinic:
30. Clinic Phone:
31. Do you currently have health coverage?

    1. Yes
    2. No
33. Medical Assistance/Insurance Co.:
34. Policy/Account No.:
36. I understand the medical information I provide will be used to determine suitability for participation in a community work program and may be released to medical professionals in the event of a medical emergency. I understand I must notify the crew leader immediately if I am injured while performing work service. I also understand that my health care coverage must pay for medical costs. If i do not have health care coverage or incur costs not covered, I must contact the crew leader within 30 days of the date of injury to file a claim or I will be fully responsible for my medical costs. I declare under penalties of perjury that the information provided in this document is true, correct and complete to the best of my knowledge and belief.
38. First and Last Name:
39. Date:
41. Parent/Guardian:
42. Date:
Leave This Blank:


44. 1. Receive an email copy of this form.
45. Email address

    This field is not part of the form submission.

46. Submit

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