AMSkier - Members Only

Camp Name

Season

Service Date (Start)

Service Date (End)

1. Physician's Full Name

2a. Work Address

2b. Cell Phone

2c. Email Address

2d. Applying for a temporary license and need a Certificate of Insurance. ( If Yes, We will email you a copy of a Malpractice certificate )

Yes No

3. Medical Specialty

4. Are you board certified in your specialty?

Yes No

If No, are you eligible?

Yes No

5. License Number

State (licensed)

Permanent or Temporary

* Please verify that your current state license will not expire while at camp. If so, please provide a copy of your renewed license as soon as possible.

6. What are your specific responsibilities and duties in regard to the work you will perform for the camp?

7. Do you plan on performing any surgery on behalf of the camp?

Yes No

8. Do you plan to administer any anesthesia on behalf of the camp?

Yes No

9. Have you ever had a malpractice claim or suit filed against you?

Yes No

10. Have you ever had your license revoked, suspended, restricted, or placed on probation?

Yes No

11a. Have you ever been the subject of an investigatory or disciplinary proceeding or reprimand?

Yes No

11b. Have you ever been convicted for an act committed in violation of any law or ordinance other than traffic offense?

Yes No

11c. Have you ever been treated for alcoholism or drug addiction?

Yes No

12. The name of your malpractice insurer (if none, indicate accordingly):

13. Does this Malpractice Policy cover you for your acts at the camp?

Yes No

To the best of my knowledge, all of the information I have provided is accurate.

Full Name

Date