Cub Scout Personal Health And Medical Form
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1CUB SCOUT PERSONAL HEALTH AND MEDICAL FORM
IMPORTANT: YOU MUST COMPLETE AND RETURN TO YOUR DEN LEADER
NAME: __________________________________________________
DATE OF BIRTH: ____/_____/______
PARENT’S NAME: _________________________________________
DEN: ___________________________
ADDRESS: _______________________________________________
HOME PHONE: __________________________
CITY: ________________________________________________ _
STATE: _________
ZIP: _______________
IN CASE OF EMERGENCY NOTIFY:
NAME: ________________________________________________
RELATIONSHIP: __________________________
PHONE: _________________________
INSTRUCTIONS: ________________________________________________
FAMILY PHYSICIAN: __________________________________________
PHONE: __________________________
PERSONAL HEALTH INSURANCE CARRIER: _____________________________________________________________
MEDICAL RESTRICTIONS OR DIFFICULTY:
____ Allergies
____ Asthma
____ Bee Stings
____ Convulsions
____ Diabetes
____ Fainting Spells
____ Heart Condition
____ Sports Restrictions
____ Other Restrictions
____ No Restrictions
____ Eyes
____ Ears
____ Nose
____ Throat
____ Digestion
____ Lungs
____ Other
Explain Restrictions or Difficulties: __________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
Does Scout take Medication. If so, what kind: __________________________________________________________________
IMMUNIZATIONS:
(Inoculations should be all current, if not, please indicate the ones that are not)
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
I give permission for full participation in Pack 141’s Cub Scout program, subject to the limitations noted herein. In case of
emergency, I understand every effort will be made to contact me or the emergency person. If neither be reached, I hereby give
my permission to the medical staff selected by the adult leader in charge to secure proper treatment for my child, including
hospitalization, anesthesia, surgery, or injections of medication.
PARENT SIGNATURE: ____________________________________________________
DATE: ___________________
Rev: 8/2/2016
Pack Medical Form
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