INROADS INTERN HEALTH FORM2016

PLEASE PRINT CLEARLY

INTERN INFORMATION

NAME LAST FIRST MI / SS# / DATE OF BIRTH / SEX
ADDRESS / PHONE

PARENT/GUARDIAN INFORMATION

NAME / RELATIONSHIP TO INTERN
ADDRESS
HOME PHONE / WORK PHONE

EMERGENCY CONTACT INFORMATION

NAME / RELATIONSHIP TO INTERN
HOME PHONE / WORK PHONE
SECONDARY CONTACT NAME / RELATIONSHIP TO INTERN
HOME PHONE / WORK PHONE
MEDICAL INFORMATION
PHYSICIAN / OFFICE PHONE
INSURANCE CARRIER / POLICY/GROUP NUMBER / PHONE (Benefit Confirmation)
Are you allergic to any medication? If so, please indicate. / Do you have any allergies? If so, please indicate.
Do you have any physical, mental, or medical condition(s) that we should be made aware of in the event of an emergency?  NO  YES
Are there any specific activities to be restricted?  NO  YES Are you currently taking any medications?  NO  YES
If you answered YES to any of the above, please explain below.

PARENT/GUARDIAN AUTHORIZATION

This health history is correct, to the best of my knowledge, and the person described above has permission to engage in all prescribed activities, except as noted. In the event I cannot be reached in an emergency, I hereby give permission to the physician of the health care facility selected by INROADS, to order x-rays, routine tests, and treatment for the health of my child, including hospitalization, securing proper treatment,and ordering injections and/or surgery for my child. Every effort must be made by the health care facility, physician, and/or INROADS to contact me in the event of any medical emergency.

Signature______DATE______

INROADS, INC.

LEARNING SUMMIT2016
WAIVER AND RELEASE FORM

MARKET:

REGIONAL DIRECTOR:

I understand that I am responsible for my behavior and actions during and throughout my participation atthe Learning Summit. I further understand that I am expected to act in a responsible and professional manner at all times, on and off site. I understand the repercussions of not adhering to the conduct standards.

In consideration of my participation in the INROADS Learning Summit, I, the Intern (and my parents and/or guardians if signatory to this document), hereby on behalf of ourselves and our respective agents, insureds, heirs, executors, administrators, successors and assigns, agree not to sue and waive, release and discharge any and all sponsors and beneficiaries of the Learning Summit, including but not limited to, both INROADS, Inc., and FILL IN LEARNING SUMMIT LOCATION(as well as their respective affiliates, subsidiaries, officers, directors, trustees, agents, employees, successors and assigns), from any and all claims, causes of action, demands, damages, judgment, costs and/or expenses (including attorney fees) or liability for death, personal injury or property damage of any kind or nature whatsoever arising out of or in the course of my participation in the Learning Summit.

(Parent signature required if under 21 years of age)

Type or print Intern’s NameDate of Birth

Intern’s SignatureDate

Type or print Parent/Guardian’s Name

Parent/Guardian SignatureDate

Summer 2016