Bsa Personal Health And Medical Record Form Class 3
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4PERSONAL HEALTH AND MEDICAL RECORD FORM –
Class 3
I. IDENTIFICATION
Age ____
Sex ___
-
Date of Birth
Name ______________________________________________
Last name
First Name
Initial
Address ____________________________________________________________
City & State___________________________________Zip____________________
Health/Accident
Insurance_____________________________________Policy no.________________
IN AN EMERGENCY NOTIFY:
Name _______________________________________Relationship________________
Address_______________________________________
Home phone
City &
State__________________________________________
Business Phone
Personal
Physician_____________________________________
Phone
IV. IMMUNIZATIONS
III. PARENTAL STATEMENT
If disease, put “D” and year
Has it ever been necessary to restrict applicant’s activities for medical reasons?
No
Yes Does applicant take medicine regularly or have special care?
Last year
No
Yes
If yes, explain.
Given
Tetanus
________
Diphtheria
________
To the best of my knowledge, the information in sections I II, III, IV, and VI is
Pertussis
________
accurate and complete. I request a licensed health-care practitioner to examine
Measles
________
applicant, to give needed immunization, and to furnish requested information to other
Mumps
________
agencies as needed. I give my permission for full participation in BSA programs,
Rubella
________
subject to limitations noted herein. In the event of illness or accident in the course of
Polio
________
such activity, I request that measures be instituted without delay as judgment of
Chicken Pox
________
medical personnel dictates.
Parent or guardian ___________________________________________________
Religious preference
(Must sign if applicant is 18 or younger)
Applicant’s signature _________________________________________________
Date signed _________________________________________________________
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