Cub Scout Information And Medical Care Permission Form
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1Cub Scout Information and Medical Care Permission Form
2008-2009
Scout Name:______________________________
Grade in September:___________
Date of Birth:___________________
2007/2008 Den Leader:___________
2007/2008 Den #: ____________
Address: ______________________________________
Phone: ______________
E-Mail Address: _____________________________________________________
Secondary E-mail address: _____________________________________________
Father’s Name: ______________________ Mother’s Name: _________________
Father’s work#: _____________________
Mother’s work #: ________________
Father’s cell #: ______________________ Mother’s cell #: _________________
If parents can’t be reached, please notify:
Name: _____________________________
Phone: ____________________
Name: _____________________________
Phone: ____________________
Name of Doctor: ______________________
Phone: _______________
Health Insurance: _____________________
Policy #: ______________
Medical Information – please check all that apply and explain below
___ Allergy to medicine, food, plant, animal or insect toxin
___ Any condition that may require special care, equipment, medication or diet
___ ADHD
____ Asthma
_____ Convulsions
___ Dentures
___ Heart Trouble
____ Contact Lenses
_____ Diabetes
___ Fainting Spells
____ Bleeding disorders
Explanation (Use reverse side if necessary): ___________________________________
______________________________________________________________________
In case of emergency, I understand every effort will be made to contact me. In the event
that I cannot be reached, I hereby give permission to the physician selected by the adult
leader in charge to secure proper medical treatment for my son, including hospitalization,
anesthesia, surgery or the injection of medication
Date: ______________
Signature of Parent: _________________________
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