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2025 FUSE Volunteer Application
GENERAL INFORMATION - ALL INFORMATION WILL BE KEPT STRICTLY CONFIDENTIAL
1.
ABOUT YOU!
Your Full Name
Mailing Address - number & street
City
State
Zip Code
Home Phone
Cell Phone
Email Address
Height
Weight
Sex
2.
T-shirt Size (adult shirt sizes)
Small
Medium
Large
Extra-Large
2XLarge
3XLarge
4XLarge
5XLarge
3.
MEDICAL INSURANCE COVERAGE & ACKNOWLEDGMENT: By my signature on this application, I agree to be responsible for any medical expenses I incur through participation in the FUSE Retreat. I also release the FUSE Foundation from any liability for injuries I may incur during the Retreat.
I do NOT have medical insurance
I DO have medical insurance
4.
MEDICAL INSURANCE COVERAGE
Company Name (Blue Cross/Shield, Medicaid, etc.)
Policy holder's Name
Policy / Group Number
5.
GENERAL MEDICAL INFORMATION
Primary Care Physician Name
Physician Address
Physician Phone
Please list any food allergies and type of reaction
Please list any dietary restrictions (vegetarian? gluten free? etc.)
Some Retreat participants may be accompanied by a service dog. Please indicate any type of adverse reaction you may have so appropriate action can be taken.
6.
Have you seen a Psychiatrist or Psychologist in the last 3 years?
Yes
No
If yes, why?
7.
Are you being followed by a Psychiatrist or Psychologist for any acute or chronic condition?
Yes
No
If yes, why?
8.
Do you currently have a communicable / infectious disease, or have you been exposed to one in the past six months?
Yes
No
If yes, what?
9.
IMMUNIZATIONS: As our FUSE participants may be medically fragile, an up-to-date immunization status is STRONGLY RECOMMENDED to attend the FUSE Retreat. Please consider this as you prepare to attend. And, if you develop any symptoms that could place others at risk, please notify Retreat staff immediately (whether before you arrive, or while you are at Retreat).
By marking "Yes", you acknowledge that immunizations are highly recommended for the FUSE Retreat.
Yes
No
