2017 CDTC Volunteer Project Registration
Project Name
Additional project(s)
ONLY APPLICABLE FOR BREW CREW PROJECTS - Please enter the code provided in your invite
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Instructions:
• Please complete one set of forms for each participant.
• Forms Required: To register participant and parent(s) of minor participants (under the age of 18) must complete, sign, and return BOTH this Registration form and the attached Volunteer Acknowledgement and Assumption of Risks & Release and Indemnity Agreement. Openings are on a first-come basis.
• Acceptance: Once CDTC has processed your forms you will receive a status confirmation letter or e-mail indicating if you are confirmed or on a waiting list for a project based on availability.
Participant Information:
Name
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Date of Birth
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Mailing Address
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City
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State
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Zip
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Phone 1
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Phone 2
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Email address
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Personal Health Information:
Is applicant covered by a hospitalization and medical care policy?
Insurance Company Name
Your answer
Policy #
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Does participant have any condition (mental, physical, emotional or otherwise), which might affect participant’s health or well-being, the well-being of others, or affect participant’s ability to engage in CDT activities?
If yes, please specify:
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Are there any limitations on participant’s ability to participate in hiking and trail work activities? Please explain (including any adaptations or modifications, appropriate or necessary.)
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Allergies (including foods, medications, bites and stings)
If yes, please specify:
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Special Diet Restrictions (if applicable)
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Medication(s)
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Condition(s)
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Dosage and Frequency
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Side Effects
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(You are required to self administer medications. You must inform project leaders where you store these medications while on the project in the event of an emergency. )
Signature:
I, (participants and parent/s of a minor participant) acknowledge that this Volunteer Registration Form contains accurate information. I will contact CDTC if any medical or health condition changes before the start of the project. I acknowledge that providing inaccurate medical or health information can create serious risks to participant or others, and/or can result in participant's dismissal from the project. I understand participant's ability to participate is contingent upon CDTC's review of all forms, including this one. I understand that although CDTC representatives may review participant's health information, the CDTC cannot anticipate or eliminate risks or complications posed by participants mental, physical or emotional condition. Participant, parent or legal guardian must sign below.
Participants Signature (By Typing Your Name Below you acknowledge your signature to this digital form)
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Date
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YYYY
Parent/Guardian Signature
Your answer
Date
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DD
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YYYY
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