Special Olympics BC – NORTH SHORE 5A Volunteer Medical Form

SOBC – North

2014-2015 Volunteer / Coach Medical Form

PERSONAL INFORMATION (PLEASE PRINT LEGIBLY):

Volunteer Name: Phone (H): Cell:

Address: City: Postal Code: Province:

Email Address: Birth Date (YY/MM/DD): Sex: M F

PLEASE INDICATE WHICH SPORT(S), DIVISION/SESSION AND ROLE(S) YOU ARE VOLUNTEERING FOR:

Sport: Division (A, B or C) or Session (1,2,or 3) or N/A:

Role (Head Coach, Ast. Coach Volunteer or Manager):

Sport: Division (A, B or C) or Session (1,2,or 3) or N/A:

Role (Head Coach, Ast. Coach Volunteer or Manager):

Sport: Division (A, B or C) or Session (1,2,or 3) or N/A:

Role (Head Coach, Ast. Coach Volunteer or Manager):

Administration Role: (if applicable)

Specify Role:

MEDICAL INFORMATION AND HISTORY Doctor: Phone: BC Care Card #:

Diabetes: Yes or No If yes: Type 1 –( Insulin Pump or Injections) or Type 2 –( Diet Pill Insulin Injections)

Tetanus Shot: Yes or No If yes, within: 5 years 10 years Asthma: Yes or No Heart Condition: Yes or No

Allergies (food/drugs/other):

Do you have or use any of the following:

Glasses Hearing Aids Dentures Contact Lenses Other

Medication: Self Administered: Yes or No (must be updated prior to any trips)

Name, Dosage and Time:

Name, Dosage and Time:

Name, Dosage and Time:

General Release: By signing below you acknowledge and give permission to Special Olympics BC-North Shore to use pictures and/or other electronic images of yourself for the purposes of promotional materials that the organization may utilize but not limited to printed material, web sites and videos/CDs. Special Olympics BC- North Shore values the privacy of its volunteers and as such protects the confidentiality of your personal information. I acknowledge that all the information given on this form is correct to the best of my knowledge and that I will update this information if it changes.

Name/Signature of Volunteer: Date:

EMERGENCY CONTACTS

Contact 1 Name: Contact 2 Name:

Home Phone: Home Phone:

Cell: Cell:

Relationship to Volunteer: Relationship to Volunteer:

Additional Space (if needed):