VOLUNTEER | HEALTH & RELEASE OF LIABILITY & CONSENT FORM NOTE: If under 18 years of age, a parent or guardian must fill out and sign this form. Group Affiliation: ______________________________ Youth/Adult information: Name: Date of Birth Age: Street: City: State / ZIP: Phone: Work Phone: E-Mail: Alternate contact person: Phone: Work Phone: If you have medical insurance, your carrier will be billed for medical charges in the case of illness or injury. Do you have medical insurance? Yes _____ No _____ Primary Insurance company: ____________________________________________ Policy no.: Group no.: Person responsible: Relationship: Secondary Insurance company: _________________________________________ Policy no.: Relationship: Family doctor: Phone: Family dentist: Phone: Health History: Pre-existing or present medical conditions: ____________________________________ ________________________________________________________________________ List any medications and dosage: ____________________________________________ ________________________________________________________________________ Allergies:_________________________________________________________________ Please check all that apply: _____ Hay fever _____Heart condition _____Frequent stomach upsets _____Diabetes _____Insect stings _____Epilepsy/Nervous disorder _____Asthma _____Physical Handicap If any of the above are checked, please give details (i.e., include normal treatment of allergic reactions): _______________________________________________________________________ _______________________________________________________________________ List any major illnesses or surgeries and when?________________________________ _______________________________________________________________________ Medical and Liability Release Statement: I understand that in the event medical intervention is needed for myself or my ward, an attempt will be made to contact the persons listed on this form. In the event I or my contact cannot be reached in an emergency during the project dates shown on this form, I hereby give my permission to the physician or dentist selected by the project leader to provide any needed medical care, including hospitalization. I understand that my insurance coverage will be used as primary coverage in the event medical intervention is needed. I understand that I and/or my ward, are volunteers in a non-profit charitable project which involves unforeseeable risks and hazards. I agree to hold Hammer & Nails, Inc., its board of directors, officers and employees harmless for any and all claims, suits or actions of whatever sort arising from my or my ward’s voluntary participation in this project. Signature:_______________________________________ Parent or legal guardian signature:____________________________________________ Name above printed:____________________________________ Date:______________ To be filled out by Hammer & Nails, Inc. Project:_______________________________________________________ Date:_________________________