Special Olympics BC – NORTH SHORE 5A Volunteer 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 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):
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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 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):
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