CLASS 1 MEDICAL FORM FOR CUB SCOUTS AND CUB PARENTS

FOR USE AT DAY CAMP AND FUNPACKS WEEKENDS

Please complete camp program you are attending:

Day Camp at ______________ (location) Date of camp:_____________

FunPack Weekend at Camp Hinds Dates_______________

Adult ________  Youth _____________

 

Name _____________________________________          Date of Birth ____________   Pack # ________

Address ____________________________________________   Adult Scouting Position ______________

City/Town _________________________________            State _______________      Zip ___________

 

IN CASE OF EMERGENCY NOTIFY:

Name _______________________________________________            Relationship __________________________

Address __________________________________________________________________________________

Home Phone ___________________________________  Other way to reach this person _________________

Physician’s Name ________________________________________  Physician’s Phone __________________

 

HEALTH HISTORY (Have you had: mark “past” or “now” or leave blank)

Sinus Trouble _______________      Asthma _________________              Fainting Spells ______________

Rheumatic Fever _____________            Earache/Infection _________                  Diabetes ___________________

Epilepsy ___________________            Tuberculosis _____________                      Frequent Diarrhea ____________

Kidney Disease ______________        Heart Trouble ____________                        For Women:

Hay Fever __________________            Severe Stomachaches ______                        Menstrual Problems __________

Know allergies or reactions to any medications? ________________________________________________

Do you tire easily? ________________________            Do you get out of breath easily? ___________________

Have you had more than a brief illness or injury in the past year? ___________________________________

If so, what? _____________________________________________________________________________

Any condition now requiring regular medication or treatment? _____________________________________

Operations or serious injuries (dates) _________________________________________________________

Any restriction of activity for medical reasons? __________________________________________________

Explain ________________________________________________________________________________

Immunizations                                    Date of Last Inoculation

Tetanus Toxin                                       __________________                                    Per State of Maine regulations: Diphtheria                                             __________________                                    “Up to date” is not acceptable.

Mumps                                                 __________________                                    Please list month and year of last

Polio                                                     __________________                                    inoculation.

Other                                                    __________________

 

PARENT AUTHORIZATION

This health history is correct so far as I know, and the person herein described has permission to engage in all prescribed activities, except as noted.  In the event I cannot be reached in an emergency, I give permission to the physician, selected by the adult leader in charge, to hospitalize, secure proper anesthesia or order injection or surgery in an emergency situation for my son or myself.

 

Signature ______________________________________________            Date ______________________________

                                    Parent or Guardian

            (   )  We have accident coverage with ____________________________________________________

                                                                        Name of Company                                         Policy #