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Staff/Volunteer Information/ Medical Form Personal Information Name: ______________________________________________

Date: ____________

Local Address: _____________________________________________________________ ______________________________________________________________ Phone: ________________________

E-mail: ___________________________

Best time/way to reach you: __________________________________________________ Date of Birth: ____________ Notify In Case of Emergency: ______________________________________________ Phone: (______) _____________________

Relationship:___________________

Insurance Company Name: __________________________________________________ Policy Number: ________________________________ Medication(s) taking _____________________________________________________________ Any adverse reactions to drugs/medications? (Penicillin, Aspirin) __________________________ ______________________________________________________________________________ ______________________________________________________________________________ Allergies? Use an inhaler? (please describe)_________________________ ______________________________________________________________________________ ______________________________________________________________________________ Have you ever had any previous allergic reaction to bee stings, foods, dust, etc? (Please describe) ______________________________________________________________________________ ______________________________________________________________________________ Please list any physical restrictions, previous medical conditions, etc. that might affect you. ______________________________________________________________________________ ______________________________________________________________________________ Can you swim? (CIRCLE ONE)

Good Swimmer

Can Swim

Non Swimmer


Experience (Check all that apply and give brief context of experience for each) Mountain Alliance ___________ In What Capacity? _________________________________________________________________________________________ ___________________________________________________________________ Working with adolescent youth ___________________________________________________________________________________ _________________________________________________________________________________________ ________________________________________________________ What ages? _______________________ Counseling ___________________________________________________________________________________ _________________________________________________________________________________________ ________________________________________________________ Group Facilitation ___________________________________________________________________________________ _________________________________________________________________________________________ ________________________________________________________ Backpacking ___________________________________________________________________________________ _________________________________________________________________________________________ ________________________________________________________ Caving ___________________________________________________________________________________ _________________________________________________________________________________________ ________________________________________________________ Rock Climbing ___________________________________________________________________________________ _________________________________________________________________________________________ ________________________________________________________ High/Low Ropes ___________________________________________________________________________________ _________________________________________________________________________________________ ________________________________________________________ Biking ___________________________________________________________________________________ _________________________________________________________________________________________ ________________________________________________________ Sailing/Boats: ___________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ Multi Media/Web design, photoshop, I movie etc. ___________________________________________________________________________________ _________________________________________________________________________________________ ________________________________________________________ Other (please specify) ___________________________________________________________________________________ ___________________________________________________________________


Interests for involvement: Are there specific areas you would like to get more experience/involvement with? Please check the boxes that are of interest.

__Alpine Tower/High and Low Ropes __ Biking Program __ Boat Program (on going/every Thursday) __Camping/Backpacking __Caving __Climbing __Community Service __Counseling/Mentoring __ Fundraising/Special Event Planning (Pancakes in the Park, Climbathon) __Group Facilitation __Leadership Initiative for Female Teens __ Membership Meeting Planning Team (Every Other Thursday) __ Multi Media __ Odd Jobs (washing sleeping bags, Gear Shed) __Other:_________________________________ Scheduling/Availability: The majority of our programming occurs after school and weekends: M-F 3:30-7pm. Please indicate time slots that you are available. Monday: Tuesday: Wednesday: Thursday: Friday: Saturday: Sunday:

Current Certifications Expiration Date

_______________________________________ _______________________________________ _______________________________________ _______________________________________ _______________________________________ _______________________________________ _______________________________________ _______________________________________

___________ ___________ ___________ ___________ ___________ ___________ ___________ ___________

Please make copies and attach to this document


References: (please list three) 1.) Name: Relationship: Phone Number: Email: 2.) Name: Relationship: Phone Number: Email: 3.) Name: Relationship: Phone Number: Email: Any other comments/needs/wishes or concerns that we should know about?: ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________


Staff/Volunteer Info