HOPE BUILDERS VOLUNTEERS

PARTICIPANT HEALTH AND MEDICAL INFORMATION

Participant Name __________________________

Date of Birth ______________________________

Church ___________________________________

The following information is required to secure medical treatment should it become necessary. Please answer all questions completely.

List any medications you are CURRENTLY taking:

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List any medical conditions for which you are CURRENTLY being treated:

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List any medications or other substances to which you are allergic:

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Health Insurance Carrier ________________________________

Phone No. (____)__________________________________

Address__________________________________________

(City, State, Zip)____________________________________

Insurance Policy Number _________________________________________________

Primary Policy Holder’s Name _________________________________________________