Capital Health

JUNIOR VOLUNTEER HEALTH SCREENING FORM

(Top Section to be completed by parent/guardian)

DATE _______________________

NAME ______________________________________________ DATE OF BIRTH___________________________

ADDRESS ____________________________________________________________________________________

_________________________________________________________________________________________________
CITY STATE ZIP CODE

PHONE __________________________________________________________________________________________

NAME OF PERSONAL PHYSICIAN ___________________________________________________________________

PERSON (S) TO BE NOTIFIED IN CASE OF EMERGENCY:

NAME ______________________________________ RELATIONSHIP _____________________________________

PHONE _______________________________

NAME ______________________________________ RELATIONSHIP ____________________________________

PHONE _______________________________

DOES YOUR CHILD:

HAVE A CHRONIC (PERMANENT) ILLNESS? _______________________________________________

HAVE ANY PHYSICAL/EMOTIONAL/MENTAL ILLNESS LIMITATIONS OR RESTRICTIONS?

_______________________________________________________________________________________

REQUIRE MEDICATION? ___________ WHAT KIND? ________________________________________

IMMUNIZATION RECORD
(Or you can attach a copy of your child’s immunization record)

DATE OF IMMUNIZATION IMMUNIZATION

st
1 __________________ Mantoux Tuberculin Tests (Two 2-step tests for new Junior volunteer)
2nd ___________________

1st ________________ MMR Vaccine (two-dose series)

2nd ________________

1st _________________ Varicella Zoster (Chicken Pox – please list date of immunization or date disease was
contracted)

1st _________________ Hepatitis B (HBV) (three-dose series)

Volunteers without HBV immunization are not placed in patient-contact areas.
2nd _________________

3rd _________________

_______________________________
Physician’s Signature