Camp Permission & Medical Form

Baie D’Urfe Mohawk Wolf Cubs

 

When? What is the date, pickup/drop of times etc…

Where? Where are we going, contact phone numbers etc…

What? What are we doing at the Camp – brief highlights

Please complete this camp permission/medical form and return it with $XX.XX per Cub ASAP. The absolute deadline for payment is XX/XX/XX. We need time to finalize our plans, buy groceries, etc…

PLEASE MAKE THE CHEQUES PAYABLE TO: Scouts Canada BDU Cubs

Cubs Name: ________________________

Address: ________________________ Home Phone: ________________________

Medicare #: ________________________ Expiry Date: ________________________

 If subject to any of the following, please mark with an "X":

__Migranes __Brochitis __Diabetes __Asthma __Convulsions __Fainting

__Requires injections (provide details below) __Other (please specify)________

Allergies (please be specific):

__to drugs: ________________________; __to food: ________________________

__other: ___________________________________________________

Currently on medication? __(if so, identify and pass on to Akela with full instructions)

Doctor’s Name: ________________________ Phone: ________________________

PARENT'S/GUARDIAN’S CONSENT AND PERMISSION TO PARTICIPATE:

I, the undersigned give permission for my child/ward to attend and participate in the XX camp, XX/XX/XX.

I hereby also give permission for the Scouter in charge, or his/her deputy, to make arrangements for surgical or medical attention for my child/ward in the event of an emergency, without necessity of my prior approval. I understand that I will be notified by the quickest possible means if this authority is exercised.

Signed: ________________________ Date: ________________________

Relationship to Cub: ________________________

 

IN CASE ON EMERGENCY, PLEASE NOTIFY:

Name: ________________________ Phone: ________________________

Please be certain that someone will be present at all times at the phone number provided.

January 24, 2001