Adult Information Adults First Name: Last Name Street Address City State Zip Home Phone - Sex: Male Female 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 AuthorizationBy submitting this form, you are enrolling your child into Cub Scotts and authorize release of all information above
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