Scouts Canada - Physical Fitness Certificate Template
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6Scouts Canada
Reset Form
Physical Fitness Certificate
NOTE:
This form is to be filled out by the parent/guardian at the beginning of each Scouting year and kept by the leader.
It is the parent’s/guardian’s responsibility to update the leader of any changes in the medical condition of their child/ward
throughout the Scouting year. (This form should be filled out for adults as well.)
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Surname:
Given Name:
Initial:
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 number: ________________________
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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If female, has youth participant menstruated?
Yes
No
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If no, has she had menstruation explained to her?
Yes
No
Pregnant?
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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):
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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
Details: __________________________________________________________________________________________
Signed, Parent/Guardian:
Date: _______________________________________
Updated, Parent/Guardian:
Date: _______________________________________
Updated, Parent/Guardian:
Date: _______________________________________
*Voluntary in some provinces
B.P.&P., Section 20000
April 2005
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