Form DI-4015 (Rev. 11/2023)

U.S. Department of the Interior

OMB Control No. 1093-0010

Expires 11/30/2026

Page 1 of 4

UNITED STATES 

YOUTH CONSERVATION CORPS 

MEDICAL HISTORY FORM

 To be Completed by 

Youth Conservation Corps (YCC) Program Applicants Only

NOTE: This information is collected under the authority of Public Law 93-408. It will be used primarily for the purpose of 

determining your eligibility for Youth Conservation Corps (YCC) service. Furnishing this information is voluntary; 

however, failure to provide the requested information may disqualify acceptance into the Youth Conservation 

Corps program.

APPLICANT MEDICAL HISTORY

Please answer the following questions regarding your background, contact, and other information

First: ________________________ Middle: ___________________ Last: ______________________ Suffix: _________

Gender:  Male  Female  Non-Binary  Self-identify as: __________________  Prefer not to disclose

Date of Birth: ________________ (mm/dd/yyyy) Age: ____

Contact Information

Street: _______________________________________________ City: _______________ State: _____ Zip: _______

Email: ____________________________________________ Phone 1: ________________ Phone 2: ________________

Are you covered under your family or any other type of health insurance?

 Yes  No If yes, list name of insurer and policy number: _____________________________________________

Primary Care Provider Name: __________________________________ Address: ____________________________ 

Have you had or are you having any of the following health conditions? (Enter “X,” or check off where appropriate) 

Allergies Recent or Recurring

Infections

Other Health Conditions 

 Hay fever

Asthma

Poison ivy

Insect stings

Skin condition

 Cold

Sore throat

Earache

Bladder infection

Intestinal infection

 Chest pain

Convulsion

Diabetic

Difficulty with balance

Fainting

Problem with blood not

clotting

 Rheumatism

Loss of weight

Lyme disease

Ulcers

Persistent cough

 Shortness of breath

Sleepwalking

Swollen/painful joints

Mental health

conditions

Heart condition

    

    

    

   

 

 Other (identify) _________________

Are you currently taking any prescribed medications?

Yes – if yes, explain on page 2

No

Are you allergic to any medications?

Yes – if yes, explain on page 2

No









Immunization history – Applicants must have received a Tdap immunization (Tetanus, Diphtheria, Pertussis)or 

boosterwithin the last ten years to participate in the YCC program.

Date of Tdap immunization or last booster (mm/dd/yyyy): ____________________________
OMB Control No. 1093-0010

Expires 11/30/2026

Page 2 of 4

Form DI-4015 (Rev. 11/2023) 

U.S. Department of the Interior

Medications 

1. Please use the table below to identify any medication(s) that the applicant is currently taking. Include the name,

dosage, and any specific instructions that a YCC program staff would need to administer medication (if necessary).

Medication Name Dosage Instructions

______________________________________________ __________ __________________________________

______________________________________________ __________ __________________________________

______________________________________________ __________ __________________________________

2. List any over-the-counter medications that YCC program staff have approval to administer if needed (i.e., Ibuprofen):

__________________________________________________________________________________________

3. List all medications to which you are allergic:

__________________________________________________________________________________________

Medical and Physical Abilities and Limitations

Below is a list of typical activities and environmental factors required for outdoor work. Please check any of the items below 

that may limit your participation in certain types of projects within the YCC program. The YCC site will work with you to 

adjust projects and accommodate any limitations to the best of their ability.

Physical and Functional Limitations

 Heavy lifting, 45 pounds and over

Heavy carrying, 45 pounds and over

Straight pulling

Pulling hand over hand

Pushing

Reaching above shoulder

 Useof fingers

Use of bothhands

Walking

Standing

Crawling

Kneeling

 Repeatedbending

Climbing, legsonly

Climbing, use of legs and arms

Use of both legs

Hearing

Corrected vision in one eye (20/20 to 20/40)

  

  

  

  

  

Environmental Factors

 Outside

Excessive heat

Excessive cold

Excessive humidity

 Dry atmospheric conditions

Excessive or intermittent noise

Dust

Slippery or uneven walking surfaces

 Working around moving objects

Working on ladders or scaffolding

Working with hands in water

Working closely with others

Workingalone

  

  

  



Please use this space to further explain any factors listed above that could require additional care or treatment.
Form DI-4015 (Rev. 11/2023) 

U.S. Department of the Interior

OMB Control No. 1093-0010

Expires 11/30/2026

Page 3 of 4

TO BE COMPLETED BY THE APPLICANT IF 18 YEARS OLD

I certify that I am familiar with the Youth Conservation Corps (YCC) program and am ready to participate in the 

program as a YCC member. I understand that I will not hold the United States Government responsible for any nonprogram accident or illness, and I authorize first aid or emergency medical care to be performed at the nearest, most 

adequate facility approved by the YCC. I authorize the sharing of pertinent medical information with a medical care 

provider in the event first aid or emergency medical care is needed.

_____________________________________ _________________________ ____________

Applicant Name Applicant Signature

(digital signature is acceptable) 

Date 

(mm/dd/yyyy)

 Emergency Contact Information:

__________________ ________________ _________________________ _________________________

Name Email Emergency Contact Number #1 Emergency Contact Number #2

TO BE COMPLETED BY THE PARENT OR LEGAL GUARDIAN IF THE APPLICANT IS UNDER THE AGE OF 18

I certify that I am familiar with the Youth Conservation Corps (YCC) program and that I give my consent for my 

child/ward to participate in the program as a YCC member. I understand that I will not hold the United States 

Government responsible for any non-program accident or illness, and I authorize first aid or emergency medical care 

to be performed at the nearest, most adequate facility approved by the YCC. I authorize the sharing of pertinent 

medical information with a medical care provider in the event first aid or emergency medical care is needed.

_____________________________________ _________________________ ____________

Parent/Legal Guardian Name Parent/Legal Guardian Signature

(digital signature is acceptable) 

Date 

(mm/dd/yyyy)

________________________________________ _____________________ __________ ________

Street City State Zip

Contact Information

__________________ ________________ _________________________ _________________________

Name Email Emergency Contact Number #1 Emergency Contact Number #2

TO BE COMPLETED BY REVEWING OFFICER

_____________________ ____________________________ ________________

Reviewing Officer's Name Reviewing Officer's Signature

(digital signature is acceptable)

Date (mm/dd/yyyy)

Additional Information. Please use this space to provide any additional information needed to complete the application.
Form DI-4015 (Rev. 11/2023) 

U.S. Department of the Interior

OMB Control No. 1093-0010

Expires 11/30/2026

Page 4 of 4

NOTICES

PRIVACY ACT STATEMENT

Authority: 16 USC 1701-1706, Chapter 37 – Youth Conservation Corps and Public Lands Corps, Subchapter I – 

Youth Conservation Corps (Youth Conservation Corps Act of 1970 (P.L. 91-378; 84 Stat. 794) as amended in 1972

(P.L. 92-597) and in 1974 (P.L. 93-408).

Purpose: This information is collected from selected applicants to determine their ability to fully participate, and to allow

the participating agencies to make necessary reasonable accommodations as appropriate.

Routine Uses: The information collected on this form may be shared in accordance with the Privacy Act of 1974 and 

the routine uses listed in the DOI Office of the Secretary (OS) System of Records Notices INTERIOR/OS-25, YCC

Enrollee Records available at https://www.doi.gov/privacy/os-notices. 

Disclosure: Furnishing this information is voluntary; however, failure to provide the requested information may

disqualify acceptance into the YCC program.

PAPERWORK REDUCTION ACT STATEMENT

In accordance with the Paperwork Reduction Act (44 U.S.C. 3501), the U.S. Department of the Interior National Park

Service and U.S. Fish and Wildlife Service and the U.S. Department of Agriculture – U.S. Forest Service, collect information 

necessary to assist the agencies in safeguarding the health, safety, and welfare of the enrollees of the YCC programs.

Your response is voluntary, but failure to complete this form will result in exclusion from participation in the YCC Program.

According to the Paperwork Reduction Act of 1995, an agency may not conduct or sponsor and a person is not required to 

respond to a collection of information unless it displays a currently valid OMB control number. OMB has approved this 

collection of information and assigned Control No. 1093-0010.

ESTIMATED BURDEN STATEMENT

We estimate public reporting for this collection of information to average 14 minutes, including time for reviewing 

instructions, gathering and maintaining data, and completing and reviewing the form. Direct comments regarding the 

burden estimate or any other aspect of the form to the Departmental Information Clearance Officer, U.S. Department

of the Interior, 1849 C Street, NW Washington, DC 20240, or via email at doi-pra@ios.doi.gov. Please do not send 

your completed form to this address.