Sea Base High Adventure Medical Form (Page 4 of 6) in pdf

FLORIDA SEA BASE

BOY SCOUTS OF AMERICA

HEALTH AND MEDICAL RECORD

CREW #

______________________

(Meets BSA Class 3 Requirements)

Name_______________________________________________________________

Date of Birth*

________________________________

Age

_________

Address_________________________________________________________________________________

City_____________________________________________ State ________Zip______________________ Phone # (_______) ________________________

Council Name _____________________________________________________ Unit # _______________ Religious Preference ______________________

*PARTICIPANTS MUST BE FOURTEEN (14) YEARS OLD BY SEPTEMBER 1 OF THE YEAR OF PARTICIPATION. SCUBA

PARTICIPANTS MUST BE FOURTEEN (14) YEARS OLD BY DATE OF ATTENDANCE. YOU MUST COMPLY WITH THIS

REQUIREMENT. SEA BASE CAN MAKE NO EXCEPTIONS.

ATTACH A PHOTOCOPY OF INSURANCE CARD. IF FAMILY HAS NO MEDICAL INSURANCE, STATE “NONE”.

Family Medical Insurance Company ____________________________________ Policy # ____________________ Phone # (_______) _________________

Address of Insurance Company ___________________________________ City, State, Zip_________________________________________________

In Case of Emergency, Notify:

Name ______________________________________________________________________ Relationship ____________________________________

Address ___________________________________________________________________________________________________________________

Home Phone # (______)____________________ Business Phone # (_______)____________________ Cell Phone # (_______)___________________

Alternate Contact ____________________________________________________ Phone # (_______) _______________________________________

This health and medical record, including limitations indicated, is valid for participation in Scouting (unit activities, camping, local and national events) for 12

months after date completed by physician. Each participant is subject to a medical recheck at Sea Base. Sea Base recognizes the right of a Scout not to have

immunizations, etc. because of religious beliefs, however, a statement signed by the parents is required, indicating that the Scout is free from contagious disease

and is able to physically tolerate the conditions as described in this form. Write Sea Base for a copy of the statement.

Sea Base meals consist of a wide variety of fresh foods, canned products, and frozen meats. The menu does not take into account special dietary concerns. If the

participant has a problem with the diet described above, contact Sea Base for a copy of the menu and plan to send supplemental food.

PARTICIPANT HEALTH HISTORY

Are you now, or have you ever been treated for any of the following: (Answer "Yes" or "No")

Sinus trouble ______ Kidney disease ______ Earaches/infections ______

Abdominal problems ______

Rheumatic fever ______

Hay fever ______

Tuberculosis ______

Fainting spells ______

Epilepsy ______

Asthma ______

Ear Problems ______

Pneumothorax ______

Seizures ______

High Blood Pressure ______

Hypertension ______

Heart trouble ______

Diabetes ______

Frequent diarrhea ______

For Women: menstrual problems ______

Any mental illness _________________________ Explain _______________________________________________________________________________

Allergies or reactions to any medication __________________________________________ Allergy to insect or jellyfish stings ________________________

Have you had more than a brief minor illness (24 hrs or more), injury or emotional difficulty during the past year? ____________________________________

If so, what? ________________________________________________________________________________________________________________

Operations, serious injuries or hospitalization with date(s), for any reason ____________________________________________________________________

Any restriction of activity for medical reasons? _________ Explain _________________________________________________________________________

Have you taken any medication for more than two (2) weeks in the past year? (What? Why?)_____________________________________________________

Are you now taking medication or treatment? (Why?)____________________________________________________________________________________

List current medications and dosages below:

MEDICATION

DOSAGE

PARENT’S/GUARDIAN’S AUTHORIZATION

REQUIRED FOR THOSE UNDER 18 YEARS OF AGE.

_______________________

____________________

I, the undersigned, have read and understand this entire form, including the sections entitled

_______________________

____________________

PHYSICIAN

PLEASE

NOTE,

THE

SEA

BASE

EXPERIENCE,

AND

RECOMMENDATIONS REGARDING CHRONIC ILLNESSES. This health history of the

_______________________

____________________

applicant is accurate and complete, and the person herein described has permission to

_______________________

____________________

engage in all Sea Base activities described, except as specifically noted on this form by the

physician or myself. If I cannot be reached in an emergency, I hereby give permission for

_______________________

____________________

health supervisor, or the adult advisor in charge, to treat, hospitalize, secure anesthesia or to

order injection, surgery or other treatment needed for the person described herein. While at

NOTE: BE SURE TO BRING MEDICATION

Sea Base, Sea Base health supervisor has permission to obtain all information connected

NEEDED WHILE AT SEA BASE.

with treatment by a physician, hospital or other treatment facility.

INFORMATION ABOVE IS ACCURATE AND COMPLETE TO THE BEST OF MY KNOWLEDGE

APPLICANT SIGNATURE (REQUIRED)

DATE

PARENT/GUARDIAN SIGNATURE (REQUIRED IF APPLICANT UNDER 18 YEARS OF AGE)

DATE

Sea Base High Adventure Medical Form Page 4

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