Peninsula-delaware conference of the united methodist church
Peninsula-Delaware Conference of the United Methodist Church 1 Day Service Project 2014 MEDICAL RECORD AND LIABILITY RELEASE FORM (Each person must bring this form with them in order to register. Persons without a form will not be able to attend.) Date of conference: April 5, 2014 Church: _________________________________________ Date signed: _______________ SECTION 1: MEDICAL RECORD AND INSURANCE
Full Name: ______________________________________________________
Date of birth: _____________________________
Address: __________________________________________________________________________________________________
City/State/Zip: ___________________________________________________
Home phone: (______) _____________________
MEDICAL INSURANCE INFORMATION
Is this person covered by a medical insurance policy? Yes _______________ No ______________
Name of policy holder: ____________________________________________
Relationship to participant: __________________
Insurance company: ____________________________________________
Medical insurance policy number: ____________________________ Check one: Group plan: _____ Individual/Family plan: _____
MEDICAL HISTORY
Blood Type: ____________________ List allergies or allergies to medications: __________________________________________________________________________
____________________________________________________________________________________________________________
List medication(s) presently taking: _______________________________________________________________________________
____________________________________________________________________________________________________________
Please describe any medical problems or conditions including mental & emotional: __________________________________________
____________________________________________________________________________________________________________
List any restrictions on sports or physical activity: ____________________________________________________________________
____________________________________________________________________________________________________________
I hereby give permission for the person listed above to be treated with the following medications: (Check medications you approve for this person to receive)
_____ Acetaminophen (temp/pain reliever) _____ Suphedrine (Sudafed/allergy) _____ Ibuprofen (temp/pain reliever)
_____ Diphenhydramine (Benadryl/allergy) _____ Loperamide (Antidiarrheal) _____ Guaifenesin (Robitussin/Cough Syrup)
List any medications person should not have: _______________________________________________________________________
____________________________________________________________________________________________________________
Doctor’s name: ________________________________________________
Doctor’s phone: (_____) _____________________
SECTION II: MEDICAL TREATMENT RELEASE AND LIABILITY RELEASE I, the undersigned parent or guardian (or self if adult 21 or over), do hereby grant permission for _______________________________ to attend the 1 Day Service Project. I hereby authorize the event staff to obtain and consent to medical treatment for my child in case of injury or illness during the 1 Day Service Project. And I hereby release and discharge the event staff, the Peninsula-Delaware Conference of the United Methodist Church, and the United Methodist Church and its representatives, employees, volunteer staff, and agents from any and all debts, judgments, or suits of any kind which may arise or be occasioned as a result of the participant’s participation in the 1 Day Service Project. I further acknowledge and understand that by participating in the 1 Day Service Project there is a possibility of physical illness or injury and my child (or self if 21 or over) is assuming the risk for such illness or injury by his/her/my participation. It is my u nderstanding that payment of any medical bills will be paid by me or by my insurance company. ___________________________________________________
_____________________________________________________
Signature of Parent, Guardian, or self if 21 or over
Name of Parent, Guardian, or self (printed)
___________________________________________________
(_______) ____________________________________________
___________________________________________________
(_______) ____________________________________________
Alternate person to call in case of an emergency
Rev. 3/2010
Effects of doxycycline treatment on skeletal muscle mitochondrial content and function from obese, diabetic subjects Amanda White Med-Into-Grad Area: Diabetes Winter 2010 University of California San Diego The increasing prevalence of the metabolic syndrome, which includes obesity and type 2 diabetes, is a major health crisis in the Western world. This disease affects approximately 24
Medical Coverage Insurance 3dsense Media School has engaged Great Eastern Life Assurance Co Ltd as our appointed insurance group. The Council for Private Education (CPE) has stipulated that all students of any Private Education Institute (i.e. 3dsense Media School) have compulsory medical insurance coverage for hospitalization and related medical treatment for the entire course durati