Mentor Medical Form Mentor Medical Form Please fill in this form and identify any known medical conditions and provide extra information if necessary to ensure your own health and safety during the mentorship program. Name * Name First First Last Last Address * Phone * Email Date of Birth * What is your preferred pronoun? he/him/his she/her/hers they/them/theirs sie/hir/hirs Other Are you Aboriginal and/or Torres Strait Islander? No Yes, Aboriginal Yes, Torres Strait Islander Yes, Aboriginal & Torres Strait Islander Prefer not to answer Is English your preferred language? Yes No If not, what is your preferred language? EMERGENCY CONTACT INFORMATION Please provide details on a minimum of 1 emergency contact person including their contact phone number and address. First Emergency Contact Name * First Emergency Contact Name First First Last Last Their relationship to you Phone * Address * Second Emergency Contact Name Second Emergency Contact Name First First Last Last Their relationship to you Phone Address MEDICAL CARE DETAILS Please complete all details to the best of your ability. Name of your family doctor and/or medical clinic * Phone number of your doctor or medical clinic * Address of your doctor or medical clinic Your Medicare number * If applicable, please enter your health fund provider and reference number Do you have an ambulance subscription? * Yes No If yes, what is your membership number? Do you hold a healthcare card? * Yes No If yes, what is your reference number? MEDICATION & CONDITIONS Please provide details of known medical conditions which may affect you and any current or recent medication or treatment that may be relevant. This will be provided to an emergency responder in order to support your specific needs and ensure your safety and wellbeing. Are you presently taking any medication? * Yes No If yes, please state name of medication, dosage and possible side effects if known etc. Do you have any known medical conditions (physical and mental health concerns)? * Yes No This could include asthma, diabetes, epilepsy, heart disease, anxiety, acquired brain injury, anaphylaxis If yes, please advise relevant details Do you have a medical plan for any known medical concerns? Yes No If yes, please outline your plan here or provide a written copy to the MATES Coordinator Do you have any known allergies? * Yes No This may include to foods, touch and medication. If yes, please provide relevant details Do you carry an Epipen? Yes No If yes, please detail how it would be accessible to emergency responders HEALTH CHECK Some mentoring activities can require a high level of physical exertion including hiking, rowing, abseiling, and camping. It is the advice of Wimmera Southern Mallee LLEN that Volunteers self-assess their level of risk and seek appropriate medical advice to ensure you are fit and able to undertake the activity as planned. Details of the Mahogany Ship Walk are below. Are you fit and able to undertake this activity? Yes No Unsure, seeking medical advice Distance: 22km / Duration: 6 hours one way / Track condition: Sand / Grade: Gentle / Start: Thunder Point car park, Warrnambool / Finish: Griffiths Island car park, Port Fairy / Nearby: Warrnambool. CONSENT TO TREATMENT - In the event that I am unable to communication and it is impracticable to engage my emergency contact(s), I hereby consent to the person in charge (or their nominee) at the mentoring activity to administer first aid to me, and consent to receiving such medical and surgical treatment (including the administration an anaesthetic) as deemed necessary by a legally qualified medical practitioner. I accept full responsibility for the payment of fees incurred should I require such treatment. I understand that in case of accident or emergency an ambulance will be called and I will be liable for any costs incurred. I give permission for my medical and emergency information to be carried by the mentoring activity coordinator or their nominee. I will immediately alert the program and/or activity coordinator if I begin to feel unwell. I provide consent to treatment as per the above statement. COVID-19 - Individuals thinking of volunteering need to consider issues of covid-19 and self-care and avoid putting themselves and others in the community at risk. This means adhering to recommended social distancing guidelines and other official guidance as it emerges. According to the Australian Government Department of Health website, ‘some people are at greater risk of getting very sick if they contract COVID-19. However, everyone is different. It is important to talk to your doctor if you have a more serious illness or more than one condition’. First Nations people can be at higher risk in any public health emergency. WSMLLEN recommends every volunteer consider the risk factors and talks to their doctor before volunteering if they have a more serious illness or more than one condition. *Volunteer insurance provided by WSMLLEN does not cover serious illness such as Covid-19. WSMLLEN has a duty of care and will ensure Volunteers have access to a suitable level of communication, best practice and prevention information, and up-to-date restriction guidelines. Individuals should only consider volunteering with due consideration to the risk factors involved and may wish to seek independent legal advice. For advice on how to seek medical help or get tested for coronavirus (COVID-19) you can contact the Victorian Department of Health and Human Services, or call the coronavirus (COVID-19) helpline on 1800 020 080 at any time. * I have read and understand the above COVID-19 statement. PRIVACY - WSMLLEN’s volunteer programs collect and administer a range of personal information for the purpose of operating the programs. It is committed to protecting the privacy of personal information it collects, holds and administers. WSMLLEN recognises the essential right of individuals to have their information administered in ways that they would reasonable expect – protected on one hand and accessible to them on the other. WSMLLEN is bound by Victorian privacy laws, the Information Privacy Act 2000 and other laws which impose specific obligations about handling information. We have adopted the principles contained in the Victorian privacy laws as minimum standards. In broad terms this means that WSMLLEN: Collects only information that is needed to effectively run the volunteer programs; Ensures that all program participants understand why we collect information and how it is administered; Use and disclose personal information only for our primary function or a directly related purpose, or for any other purpose only with the person’s explicit consent; Store personal information securely, protecting it from unauthorised access; Give participants access to their own information and the right to correct it. * I have read and understand the above privacy statement. DECLARATION * I declare that the information provided in this medical form is accurate. I am aware that failing to disclose information could impact on the treatment I receive in the event of a medical emergency. Name Name First First Last Last If you are human, leave this field blank. Submit
