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Crew Member Medical Information Sheet

  1. To assist in your job or task placement, please check all that apply (if you have had or are now experiencing):

  2. Do you have medical restrictions limiting the work you can do?

  3. Are you currently under a doctor's orders regarding work?

  4. Do you currently have health coverage?

  5. I understand the medical information I provide will be used to determine suitability for participation in a community work program and may be released to medical professionals in the event of a medical emergency. I understand I must notify the crew leader immediately if I am injured while performing work service. I also understand that my health care coverage must pay for medical costs. If i do not have health care coverage or incur costs not covered, I must contact the crew leader within 30 days of the date of injury to file a claim or I will be fully responsible for my medical costs. I declare under penalties of perjury that the information provided in this document is true, correct and complete to the best of my knowledge and belief.

  6. Leave This Blank:

  7. This field is not part of the form submission.