On-line Application for Joining the Cub Scouts
Boy's First Name: Last Name
Street Address
City State Zip
Home Phone -
Grade: Date of Birth / /
Ethnic Background:
Boys' Life Magazine comes to you free with your initial invenstment. Check here if you do NOT wish to recieve it:

Adult Information
Adults First Name: Last Name
Street Address
City State Zip
Home Phone -
Sex: Partners Date of Birth / /
Occupation Business Name
Street Address
City State Zip
Business Phone -
Previous Scouting experience (Fill out questionnaire)

Applicants Personal Health History
Allergfies (Please list if checked):

General Information (Check ALL that apply)

ADHD Asthma
Cancer/leukemia Convulsions/seizures
Diabetes Heart Trouble
Hemophilia High Blood pressure
Kidney disease
List any medications to be taken at camp

List any physical or behviorial conditions that may affect or limit full participation in swimming, backpacking, hiking long distances, or playing strenuous physical games


List equipment needed such as wheelchair, braces, glasses, contact lenses, etc:

Immunizations (give date of last incoulaiton)

Tetanous toxoid/ / Diphteria/ /
Pertussis/ / Measles/ /
Mumps/ / Rubella/ /
Polio/ /

Name of personal physician
Phone-
Person health/accident insurance carrier
Policy Number

Parent Authorization
By submitting this form, you are enrolling your child into Cub Scotts and authorize release of all information above

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