Adult Participation Form
I will be volunteering at
Bear Creek Lake Park
Reuter Hess
Both
Personal Information
Name (First and Last Name)
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Indicate phone type
Home
Work
Mobile
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
example@example.com
T-Shirt size
S
M
L
XL
XXL
Emergency Contact
Name
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
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Health History
Date of last health exam
-
Month
-
Day
Year
Date
Were there any complicating medical problems noted?
Yes
No
If yes, please explain.
Health History: Please check any conditions you have had
Ear Infections
Convulsions
Diabetes
Heart Defect/Disease
Bleeding/Clotting Disorder
Hepatitis B Carrier
Hypertension
Musculoskeletal Disorder
Plant/Pollen Allergies
Insect Sting Allergy
Drug Allergies (specify)
Other Allergies (specify)
German Measles
Mumps
Chicken Pox
Please explain health conditions checked above
Date of Last Tetanus Booster
-
Month
-
Day
Year
Date
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Other health conditions
Frequent Constipation
Menstrual Cramps
Sleep Disturbances
Special dietary regimen
Emotional disturbances
Fainting
Hearing Impairment
Wear Glasses
Wear Contact Lenses
None
Other
Please explain other health conditions checked above
Are there other health concerns the Health Supervisor/Camp Directors should be aware of?
Yes
No
If Yes, please explain health concerns Health Supervisor/Camp Directors should be aware of.
Are you taking any medication?
Yes
No
If Yes, please list medications you are taking.
Since your last exam, have you had
A serious injury requiring medical attention?
Treatment in a hospital or emergency room?
An illness lasting more than five (5) days?
A surgical operation or fracture?
Any restrictions concerning physical activities?
None of the above.
Other
Give dates and explain any of the above checked
Do you consider yourself to be in good health and able to participate in normal program activities?
Yes
No
If no, please explain
Dietary considerations
Are you vaccinated against Covid 19
Yes
No
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Signatures
By checking the following items you agree to the terms and conditions therein.
If I am exposed to contagious disease in the three weeks prior to event/program, I will notify the director.
To the best of my knowledge, this health history is correct.
In case of emergency, I give my permission to persons representing Girl Scouts of Colorado to see that I receive appropriate emergency medical or surgical treatment, and/or hospitalizaition if necessary. It is understood that every effort will be made to reach teh person named above as my emergency contact.
I, being an adult over the age of 18 hereby consent that my name, image, and likeness, as shown in the video-tapes, photographs, motion picture film and/or electronic images for which I posed, and/or audio recordings made of my voice may be used by Girl Scouts of the U.S.A., its assigns or successors, in whatever way they desire, including television and Web sites; furthermore, I hereby consent that such photographs, films, recordings, electronic images, and the plates, tapes and/or software from which they are made shall be their sole property, and they shall have the right to sell, duplicate, reproduce and make other uses of such photographs, films, recordings, electronic images, plates, tapes and software as they may desire free and clear of any claim whatsoever on my part.
Date Signed
Submit
Should be Empty: