Medical and Liability Forms

Supplementary Forms

Please contact the Amizade office at 304-293-6049 or volunteer@amizade.org for any questions about this process

PLEASE REMEMBER THAT YOU MUST COMPLETE THE ENTIRE MEDICAL FORM BEFORE SUBMITTING.

1. Choose one:

Choose one: Mr.

Ms.

Mrs.

*
2. Name:

Name: Last
First
Middle Initial

*
3. Gender:

Gender: Male

Female

*
4. Date of Birth:

	MM		DD		YYYY
Date of Birth:	Date of Birth: Date of Birth: Month	/	Day	/	Year

*
5. Country of Citizenship:

Country of Citizenship: Country:

*
6. For the questions above:

For the questions above: I certify that all information is correct to the best of my knowledge.

Medical and Liability Forms

Supplementary Forms

1. Choose one:

*2. Name:

*3. Gender:

*4. Date of Birth:

*5. Country of Citizenship:

*6. For the questions above:

*
2. Name:

*
3. Gender:

*
4. Date of Birth:

*
5. Country of Citizenship:

*
6. For the questions above: