Gender *
Date of Birth *
Date of Birth
Physician's Contact *
Physician's Contact
(e.g. not able to climb a ladder, not able to lift heavy objects, not able to get on the roof, etc...)
(please include the approximate date of the procedure)
(include dosages)
I hereby grant CWE the use of the above medical information as needed in its discretion to determine my fitness to serve as a volunteer for CWE, as well as in the event that I need first-aid treatment or other medical services rendered in connection with an emergency during my service as a volunteer with CWE. *
Date *
Date