Senior Community Service Employment Program Participation Form

Senior Community Service Employment Program Participation Form - Alaska Page 2

MEDICAL

Yes !

No !

Are you currently seeing a doctor or counselor?

Yes ! No !

Are you taking any prescriptions medications?

If yes, please list ______________________________________________________

! Standing

! Lifting

! Walking

Do you have any limitations

. ___________________

Please indicate any conditions, which would affect your work

! Bee stings

! Penicillin

! Allergies

! Other

__________________________

In case of emergency, this will authorize medical treatment to be provided to the applicant.

In case of emergency, please notify:

____________________________________________________

Name

____________________________________________________

Address

____________________________________________________

Phone

Legal

Yes ! No !

Have you been convicted of a felony?

If yes, Please explain

_________________________________________________________________________

Yes ! No !

Are you on parole or probation?

______________________________________

__________________________________________

Parole/probation officer name

Phone Number

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Senior Community Service Employment Program Participation Form - Alaska Page 2