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(STST"6@@``   ? KZ   6 Z hZ  ]CHNKINK )TEXTTEXT9STSHSTSH;2STSHSTSH;STSHSTSH=FDPPFDPP@FDPPFDPPBFDPPFDPPDFDPCFDPCFFDPCFDPCHFDPCFDPCJFDPCFDPCLFDPCFDPCNFDPCFDPCPFDPCFDPCRFDPCFDPCTFDPCFDPCVFDPC FDPCXFDPC FDPCZFDPC FDPC\Updated Aug 2010 Medical History Form Name (Last, First, Middle Initial) Address (Street, City, State, Zip Code) Do you have health and accident insurance? Yes No Insurance Company Policy Number Date of Birth (mm/dd/yy) Primary Phone Gender Male Female Height Weight CORPSMEMBERS & LEADERS SHOULD READ ALL OF THE FOLLOWING INFORMATION AND SIGN BELOW. HEALTH INFORMATION AUTHORIZATION I acknowledge that participation as a Corp Member or Crew Leader of Southwest Conservation Corp Program activities, described in the SCC Corp Member Handbook ( SCC Program ), involves potentially dangerous activities that challenge a person s physical and mental limits, based upon the number and types of participants, terrain, temperature, weather conditions, equipment, animals, and actions of others. These risks include property damage, personal injury, mental distress, and death. I understand participation in the SCC Program demands a very high level of exertion and stamina. I know participants must be able to lift up to 50 pounds, work at high altitudes, hike long distances, carry equipment, and work in steep, rugged terrain. Because of these SCC Program conditions: I authorize SCC to have access to the otherwise private health information included in this form in order to assess my suitability for program participation, and to refer me to medical care if it becomes necessary. I certify that I am physically fit, have sufficiently prepared for SCC Program participation, and have received no advice from a qualified medical professional not to participate in the program. I certify that there are no known health-related reasons which prevent my participation in the SCC Program. I certify SCC encouraged me to have a physical examination by a qualified health professional prior to SCC Program participation. I HAVE READ THIS DOCUMENT AND I UNDERTAND IT. I SIGN IT OF MY OWN FREE WILL. ___________________________ ____ ____________________________________ ______________ PRINTED name Age Signature (if under 18, parent Date or guardian must also sign) PARENT/GUARDIAN WAIVER AND RELEASE FOR CREW MEMBERS UNDER AGE 18 I am the parent or legal guardian of the minor child, and acting in this capacity, consent to the minor s participation in the SCC Program, and to all terms of the waiver and release of liability stated above, which I have read and fully understand. ________________________________ ____________________________________ ______________ PRINTED name of parent/guardian Signature of parent/guardian Date Social Security # E-mail Address Insurance Telephone Number In order to provide the safest possible environment for our participants your honesty and openness on the following questions are essential. We wish to provide the most appropriate accommodation to any conditions and respond to any incident with appropriate treatment, therefore, please be as detailed as possible. Failure to disclose medical conditions on this form may be grounds for non-participation or dismissal from the program. General Health Questions Please check either yes or no to indicate whether you have had any of the following conditions in the past two years: Chronic or infectious illness or condition Yes o No o Hospitalized for any reason Yes o No o Any type of surgery Yes o No o Frequent headaches or migraines Yes o No o Head Injury (consc/unconsc) Yes o No o Glasses or contacts Yes o No o Dizziness or fainting Yes o No o Chest Pains Yes o No o Seizures/neurological problems Yes o No o Back Pains/Problems Yes o No o Are you currently under the care of a physician or psychologist Yes o No o History of cardiovascular disease in your family Yes o No o Cognitive/bahavioral concerns Yes o No o Heart Condition Yes o No o Diabetes Yes o No o Hepatitis Yes o No o Eating disorder Yes o No o Mental health concerns Yes o No o Do you use tobacco Yes o No o Are you pregnant Yes o No o Heat Injuries Yes o No o Bleeding or blood disorders Yes o No o Gastrointestinal problems Yes o No o High blood pressure Yes o No o Problems with joints/bones Yes o No o ADD/ADHD Yes o No o Please explain any  Yes answers. Please note the question referred to and state the specific date and extent of injury/illness. Being thorough may eliminate the need for further follow-up from SCC staff. If currently under the care of a physician or psychiatrist please list their name, address and phone number. Allergies Please list all allergies to Medications, Foods, or Environment (bee stings, plants, etc.). Attach additional sheets if necessary. (If you have been prescribed Epinephrine for any allergies you must bring 2 personal EPI-Pens with you) Medications o I take NO medications o I take medications as follows: (attach add l pages if necessary) Medication #1: ______________________________________ Dosage: __________ Specific times each day: _____________ Reason for taking: ________________________________________________Have been on medication since: ______________ Side effects: ________________________________________________ Do you take this medication on your own? Yes or No Medication #2: ____________________________________ Dosage: __________ Specific times each day: _____________ Reason for taking: ________________________________________________Have been on medication since: ______________ Side effects: ________________________________________________ Do you take this medication on your own? Yes or No Medication #3: ____________________________________ Dosage: __________ Specific times each day: _____________ Reason for taking: ________________________________________________Have been on medication since: ______________ Side effects: ________________________________________________ Do you take this medication on your own? Yes or No Allergy Date of Last Reaction Severity of Reaction Description of Reaction Treatment Rx Epinephrine Yes/No Yes/No Staff Approved Staff Reviewed Do you have any medical conditions that might interfere with your performance of the job duties? Do you need special accommodations from SCC? In the event of an emergency SCC staff must be able to contact a designated emergency contact. Please provide at least one primary phone number for each contact. 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