electronic health waiver - WaiverElectronic

VOLUNTEER HEALTH DISCLOSURE AND CONTACT INFORMATION

NOTE: CFI requests this information to endeavor to understand issues in the field, and in the event of an emergency. If volunteer is pregnant, has not had a tetanus or booster shot in the last 10 years, or has any current, chronic or episodic condition/s such as asthma, allergies, diabetes, a heart condition, an orthopedic injury, a seizure disorder, previous serious reaction to high altitudes or any other condition/s that may be triggered or complicated by high altitudes, extreme weather conditions or distance from medical facilities, the volunteer (and parent of a minor) should consult with their medical care provider before participating in a CFI project, to determine if volunteer can participate without causing harm to himself/herself or others.

Volunteer Information:

Name: * Please enter your name.

Gender: * Please select one here.

Mailing Address: *

Please enter address.

Home Phone * Please enter your phone number.

Work Phone Please enter your phone number.

Cell Phone Please enter your phone number.

Email: * Please enter your email.

Emergency Contact information：

Name: * Please enter your name.

Relationship * Please enter your answer here.

Mailing Address *

Please enter address.

Home Phone * Please enter your phone number.

Work Phone Please enter your phone number.

Cell Phone: Please enter your phone number.

Email: * Please enter your email.

1. Does volunteer carry health insurance? *

Yes

Please select at least one choice above.

2. Does volunteer have any condition/s (mental, physical, emotional or otherwise) which may affect volunteer’s well being, the well being of others, or affect volunteer’s ability to engage in CFI activities, particularly at high altitudes? *

Yes

Please select at least one choice above.

if “yes,” please specify (including any suggested modification/s): Please enter your answer here.

3. Does volunteer have any allergy/s or asthma? *

Yes

No known allergy/s or asthma

Please select at least one choice above.

If yes, please list known allergy/s (to food, insects, plants, etc.) or asthma, any medication/s taken for the condition, and explain triggers, symptoms, reaction (include severity of reaction or complication - for example, anaphylaxis): Please enter your answer here.

4. Has volunteer ever experienced high altitude sickness, either mild (headache, nausea) or severe HAPE, HACE)? *

Yes

Please select at least one choice above.

If yes, please describe frequency and severity of symptoms experienced Please enter your answer here.

5. Please list any medication/s taken by the volunteer that CFI should know about in the event of an emergency. For each medication, please identify the condition for which the medication is taken, the dosage and any known side effects/restrictions or effects of a missed dose: * Please enter your answer here.

I agree to inform project leaders where I/my child stores medications while on the project in the event there is an emergency. I also agree I/my child will bring first aid supplies recommended by my/my child’s medical care provider for my/my child’s personal use, including those to counteract potential serious allergic reaction (for example, anaphylaxis resulting from allergy to bee stings). I acknowledge that providing inaccurate health information or falsifying health information can create serious risks to volunteer or others, and/or can result in volunteer’s dismissal from the project.

Volunteer and parent of a minor volunteer agree: The information provided on this form is accurate to the best of my knowledge. Volunteer must sign below. A parent must also sign if volunteer is a minor (those under 18 years of age).

Volunteer Signature *

Click to sign

Please sign here.

Date *

Please enter valid date.

Volunteer Name * Please enter your name.

Volunteer Date of Birth: *

Please enter valid date.

Parent or Guardian Information (Ignore the section below if there are no minors)

Parent or Guardian Signature

Click to sign

Please sign here.

Date

Please enter valid date.

Parent or Guardian Name: Please enter your name.

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