Student Medical Form Nyc Minority Program

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National Hispanic Environmental Council
COMBINED NYC INSTITUTE/YCC PROGRAM STUDENT MEDICAL FORM
THE 9th ANNUAL
NYC MINORITY YOUTH ENVIRONMENTAL TRAINING INSTITUTE
“8 Days of Learning, A Lifetime of Experience”
June 26 – July 3, 2014 • New York City
(You must fill out this Form completely)
Please fill out this form and include it with your Application package. You must submit the Medical Form for your applica-
tion to be considered. You must fill out the Form completely, if you leave out any information, your application will not
be considered. Use additional paper as necessary.
NHEC needs this information so that Institute staff will know—in advance—of any special medical conditions you may
have, rather than learning about them during the Institute, should a medical emergency arise. Also, in the event of injury
or illness, this Form provides medical personnel with key information regarding your medical history. Because of this, it is
vital that you be as complete, accurate, and truthful as possible. This Form is not used to screen out applicants.
NOTE: This Medical Form will be used for both the NYC Institute and the Youth Conservation Corps job program (YCC),
should you be hired by the Forest Service after the Institute for YCC. The sole purpose of this combined form is for the
convenience of applicants, so you do not have to fill out another Medical Form.
GENERAL INFORMATION
Your Name: _______________________________________________________________________________________
Street Address: ____________________________________________________________________________________
City, State: ____________________________________________________ Zip Code: ___________________________
Cell Phone: _______________________________________________________________________________________
E-Mail (student’s and parents, if available): :
Student’s:____________________________________ Parents: _____________________________________________
How old are you now? (Example 17, 18, etc.) ____________________________________________________________
Birthdate: Month ____________________ Day _____________________ Year _________________________________
US Citizen: ❑ Yes
❑ No
Permanent Legal Resident
❑ Yes
❑ No
PERSON TO NOTIFY IN CASE OF EMERGENCY
Name: ___________________________________________________________________________________________
Street Address: ____________________________________________________________________________________

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