Group Name

Name of Cub Scout

male

female

Date of Birth

Address

Contact person

Name

Phone Number

Family doctor’s name

Name

Phone Number

Medicare Number

Medical Insurance Fund

Ambulance Subscriber

YES/NO

Allergies or reactions to bees, wasps, ants, plants, food, drugs chemicals?  Please circle which.

YES/NO

If YES, then please describe reaction and treatment required.

Bronchial or respiratory complaints e.g. asthma, hay fever, croup.

YES/NO

If YES, please give details of symptoms and medication required, including frequency of dosage.

Currently having medical attention for a chronic health problem e.g. Migraine, Diabetes, Epilepsy, Heart Condition or any other?

YES/NO

If YES, please describe medication.

Serious illness or injury in the past 12 months e.g. broken leg, surgery, etc. If YES, please describe.

YES/NO

Any ear or hearing problems, e.g. deafness, discharge, frequent infection.  Please describe.

YES/NO

Any eye or visual problem e.g. contact lenses.  Please describe.

YES/NO

Sleepwalking, bedwetting, carsickness.  Please circle.

YES/NO

Any dietary restrictions, e.g. dairy intolerance, kosher food, vegetarian etc.  Please describe.

YES/NO

Approximate date of last tetanus immunisation or booster.

Is there any other health problem; physical, intellectual, emotional that should be known?

YES/NO

Can your child receive blood/blood products in an emergency?

YES/NO

Can your child be photographed with the possibility of the photo being published for P.R. purposes ?

YES/NO

I authorise the Leaders of the Sherbrooke Forest District, when unable to communicate with me, to arrange for such medical or surgical treatment as may be deemed necessary for my child.  I agree to pay all such medical expenses incurred on behalf of my child.

Signed:  Parent / Guardian

Dated:

This form is confidential and will be seen by the Leader in Charge and the First Aider only.  If medical attention is required and you are unavailable, this form will be shown to the doctor before treatment is given.

Thank you for taking the time to complete this form.