Parent or legal guardian should complete form for all children under 18 years participating in AMC program.
PLEASE READ CAREFULLY
Participants (or parents/guardians, if appropriate) must read and sign below.
Participant acknowledgement of accuracy and understanding. By signing this form, I am declaring that, to the best of my knowledge, I have completed the questionnaire accurately. I also understand that by knowingly filling out the form inaccurately, or by withholding pertinent information about my health, I could potentially be increasing the risk to myself or others.
Consent to accept aid. By signing this form, I am giving consent and permission for AMC staff, volunteers, representatives, or contractors to provide medical care to me or to my child, to transport me or my child to a medical facility or to seek the aid of emergency medical services as deemed appropriate. I further authorize AMC staff, volunteers, representatives, or contractors to render whatever treatment they consider necessary for my or my child’s health, and I agree to pay all costs associated with that care and transportation.After pressing SUBMIT you will be redirected to a webpage to sign this Health Questionnaire. A copy will then be emailed to you for your records.