Contact in case of emergency
Name________________________________________________Relation________________________
Phone (H)(______)______________ (W) (______)________________(C) (_______)________________
Address____________________________________________________________________________
City_______________________________________________ State_________ Zip________________
In case of emergency the nearest hospital to the site may be used. The information below is needed by any
hospital or medical practitioner not having access to the volunteer's medical history:
Allergies (medicines, food, etc.)_________________________________________Blood Type________
Date of last Tetanus Shot____/____/____
Medications Currently Taking ____________________________________________________________
____________________________________________________________________________________
Have you had any injuries, surgeries or illnesses in the past 6 months? ___________________________
If yes, please List: _____________________________________________________________________
____________________________________________________________________________________
Personal Physician (Name) _____________________________________________________________
Phone (______)_______________________________________________________________________
Address ____________________________________________________________________________
City ___________________________________________________ State _________ Zip ___________
Health Insurance Coverage
(Company) __________________________________________________________________________
Policy Number _______________________________________________________________________
Insurance Agent ______________________________________________________________________
Phone (______)_______________________________________________________________________
I have carefully read this AGREEMENT and I fully understand its contents. I am aware that this is a release
of liability and a contract between myself and the museum. I am signing this document on my own free will.
Executed at Ellsworth, Maine on (date) _____/_____/_______.
Volunteer's Signature___________________________________________________________________
Parent Signature _____________________________________________________________________