SBOC Volunteer Contact Information

SHRINE BOWL EMERGENCY INFORMATION FORM

VOLUNTEER ADULT STAFF

Please Print in Ink or Type:

_____________________________________ _______________________________________ __________________________

( Last Name) (First Name) (Middle Initial)

Date of Birth: _____________________________ Social Security Number______________________

(Month / Day / Year)

Home Address: ____________________________________________________________________________

_________________________________________________________________________________________

City: ___________________________ State: _________Zip Code: ______________

Home Phone Number: (_______)___________________ Cell Number: (_______)______________________

Area Code Area Code

School Name: ____________________________________________________________________________

School Address: ____________________________________________________________________________

_________________________________________________________________________________________

City: ___________________________ State: _________Zip Code: ______________

School Phone Number: (_______)___________________ Cell Number: (_______)______________________

Area Code Area Code

Email_____________________________________________________________________________________

Alternate Emergency Contact Person: _________________________________________________________

Daytime Phone: (_______)____________________ Page or Cell (_______)____________________

Area Code Area Code

Nighttime Phone: (_______)____________________ Page or Cell (_______)____________________

Area Code Area Code

Medical Insurance Company Name: _______________________________________________________

Policy Number/s: ____________________________________________________________________

____________________________________________________________________

SHRINE BOWL MEDICAL HISTORY

VOLUNTEER ADULT STAFF

The following questions are intended to provide the Shrine Bowl Medical and Athletic Training staff’s background regarding your medical history. Please be as honest and frank as possible with your responses.

Circle the appropriate answer

ALLERGIES

1. YES NO Are you allergic to any type of Medications? If YES please list:

_______________________________________________________________________

2. YES NO Are you allergic to anything else, (Bee’s, Food, etc.)? If YES please list:

_______________________________________________________________________

Circle the appropriate answer

GENERAL HISTORY

1. YES NO Are you currently taking any medication(s)? If YES, please list the name and

Dosage_________________________________________________________________

_______________________________________________________________________

2. YES NO Do you have a history of Asthma? If YES, List prescribed medication

_______________________________________________________________________

3. YES NO Have you ever been knocked out or experienced a concussion? If YES, how many

(TIMES)__________________ (DATE OF LAST INCIDENT) __________________

4. YES NO Are you Diabetic? (Insulin dependent or Non-insulin dependent)

5. YES NO Have you ever been told you have a heart murmur or heart disease?

5. YES NO Are you missing any of your paired organs (eyes, kidneys, testicles, etc.)

6. YES NO Is there a known history of mental disorder, convulsions, or seizures?

Circle the appropriate answer

BONE & JOINT

1. YES NO Do you have any permanent deformity or disability? If YES describe _____________

______________________________________________________________________________

2. YES NO Have you had a shoulder dislocation or separation since entering high school?

3. YES NO Have you ever had a "BURNER" or "STINGER"? How many THIS YEAR?

______________________________________________________________________________

4. YES NO Have you ever been advised to have surgery for a bone or joint condition?

5. YES NO Have you ever had an injury to your back or neck?

6. YES NO Have you had a knee injury since entering high school? If YES, describe

______________________________________________________________________________

7. YES NO Do you have a pin, plate, or screw somewhere in your body? If YES, what and

where? ________________________________________________________________

______________________________________________________________________________

8. YES NO Have you had a fracture during the past TWO YEARS? If YES, what was?

fractured?______________________________________________________________

MEDICAL HISTORY CONTINUED

Circle the appropriate answer

EYES & DENTAL

1. YES NO Do you wear (glasses) or (contact lenses) when practicing and playing? If YES,

circle which.

2. YES NO Do you wear a dental appliance? If YES, describe ____________________________

_______________________________________________________________________

3. YES NO Do you have dead teeth? If YES, give the approximate location. ________________

_______________________________________________________________________

In the space below give any medical information you feel is essential to your well-being and our ability to provide quality

health care for you during your week with the Shrine Bowl.

If you have any questions or concerns please feel free to contact:

Shrine Bowl of the Carolinas

Athletic Training Committee, Chairman

Michael J. Guerrero, M.Ed., ATC, LAT

204 E. Parker St.

Smithfield, NC 27577

Phone: 919-868-7422

Fax: 919-934-7455

Email: mgatc@aol.com

SHRINE BOWL MEDICAL HISTORY

MEDICAL HISTORY CONTINUED

Return all completed forms to Mike Guerrero by November 16, 2010