Medical Form

IF YOU ARE ATTENDING ANY FRIENDSHIP CIRCLE EVENT THAT REQUIRES TRANSPORTATION, THIS FORM MUST BE ON FILE WITH THE JEWISH COMMUNITY CENTER, SONOMA COUNTY.

WE MUST HAVE AN UPDATED FORM EACH YEAR. 

 

Thank you for your cooperation,

JALENA MAYS, Program Director                                                                      
707-528-1476, jalenam@gmail.com

 

 Consent for Emergency Treatment & Personal Confidential Questionnaire

I hereby authorize the escort of the trip to obtain medical treatment for me; I will be responsible for all payments. 

I hereby waive, release and discharge any and all claims for damages, death, personal injury or property damage against the Jewish Community Center, Sonoma County, their staff, volunteers and agents for my participation in this activity.
Accept or Decline
  yes
 no
Date Form Completed
First Name
Last Name
Email
Phone
Cell Phone
Birthdate
Insurance Company
Ins. Policy/ Member Number
Medicare Number
Allergies / Health Problems
Medications
Physician's Name
Physician's Phone

In case of emergency notify: (someone not on the trip)
Emergency Contact Name
Emergency Contact Phone
Emergency Contact Cell Phone
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