Physical Fitness Form For Non-Members - Scouts Canada
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Scouts Canada
Physical Fitness Certificate for Non Members
NOTE:
This form is for use by Parent-Guardians or Volunteer Helper/Resource Persons participating in Scouting activities.
This information is collected to assist the Scouter in charge should a medical emergency arise. In accordance with applicable
Privacy Legislation, this information will not be used for any other purpose.
Surname:
Given Name:
Initial:
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Date of Birth:
Age:__________
Male
Female
Address:
City:
Province:
Postal Code:
Home Phone #:
Physician’s Name:
Phone # _____________Scout Group Name:
*Provincial Medical Plan:
Insurance Coverage Held:
Emergency Contact Name: _____________________________ Phone #:
Emergency Medical Information
:
□
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Does the applicant have any allergies? Yes
No
If yes, please indicate below.
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Medicine
Insect Bites
T
oxins
Food
Smoke
□
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Plants
Animals
Other
Details:
Has had, please check (x)
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Appendicitis
Mumps
Chicken Pox
Meas s
le
Kidney disease
□
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Rheumatic Fever
Scarlet Fever
Heart condition
Other
Is subject to any of the following, check (x) and give details:
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Asthma
Contact Lenses
Headaches
Fainting spells
Bleeding disorders
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HIV
Ear problems
Diabetes
Hernia
Back problems
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Motion sickness
Cramps
Convulsions
Sleepwalking
Nightmares
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Bed wetting
Other
Details:
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Does the participant require special care, medication or diet?
Yes
No
Details:
D ate of most recent physical examination (Month and Year):
Date of last tetanus sh
ot
(Month and Year):
□
□
Swimming abilities:
Non-Swimmer
Swimmer
(Highest Level Achieved):
□
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Has it ever been necessary to restrict the applicant’s activities for medical reasons?
Yes
No
Signed,
Date: _______________________________________
*Voluntary in some provinces
B.P.&P., Section 20000
August 2006
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