Colorado Bsa Camps Health And Medical Record

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NOTE: ALL
Colorado Boy Scout Camps Health & Medical Record
MEDICATIONS
This form is valid for 24 months for persons under 40 years of age and 12 months for persons 40 years of age and older.
MUST BE IN
Personal Health and Medical Record—Class 1 and 3
Instructions: By completing sections 1, 2, and 3, this form qualifies as a Class 1 medical history. By completing all sections (page 1
ORIGINAL
and 2); this form qualifies as a Class 2 or 3 medical record.
CONTAINER WITH
Who needs a Class 1? Anyone attending Cub Scout Day Camps and any overnight activities less than 72 hours.
PHARMACY LABEL!
Who needs a Class 3? Anyone attending a high Adventure Base or Boy Scout Camp (longer than 72 hours).
1. Personal and Emergency Contact Information
Name: __________________________________ Date of Birth: ____________ Age: _________ Sex: __________
Address: __________________________________________ City, State, Zip ________________________ Phone: ______________
Name of Mother/Guardian/Spouse: _____________________
Name of Father/Guardian/Spouse: ______________________
Phone: _________________ E-mail:____________________
Phone: _________________ E-mail:____________________
Address: __________________________________________
Address: __________________________________________
City, State, Zip: _____________________________________
City, State, Zip: _____________________________________
____________________________________
____________________________________
Place of Employment:
Place of Employment:
Phone: ____________________________________________
Phone: ___________________________________________
If above persons are not available in the event of an emergency, please contact:
Name: ____________________________ Phone: _______________ Name: ___________________________ Phone: _______________
Adults authorized to take youth to and from the event:
(You must designate an adult. Please include phone number)
Persons NOT authorized to take youth to and from the event:
_______________________________________________
_____________________________________________________
________________________________________________
_____________________________________________________
________________________________________________
_____________________________________________________
2. Health History Information
YES
NO
Explain
Name of Primary Physician: ______________________________
Serious Illness
Phone; ______________________________________
Serious Injury
City, State: ___________________________________
Medical Insurance Provider: ______________________________
Deformity
Carrier’s Name: _______________________________
Surgery
Policy or Group Number: ________________________
Ears, Eyes
Medicaid ID #: ________________________________________
Nose, Sinus
Medications taken in the last 30 days: ______________________
_____________________________________________________
Teeth/Tonsils
_____________________________________________________
Chest, Lungs
Medications to be continued at event and dose: _______________
_____________________________________________________
Heart Murmur
_____________________________________________________
Rheumatic Fever
_____________________________________________________
Appendicitis
Special Instruction related to any medications: ________________
Kidney or Urine
_____________________________________________________
Menstrual problems
_____________________________________________________
Any activities participant cannot participate in: ________________
Hernia
_____________________________________________________
Back, Limbs, Joints
_____________________________________________________
Sleepwalking
Food Allergies: ________________________________________
Nervous Conditions
Plant Allergies: ________________________________________
Other (explain)
Insect/Animal Allergies: _________________________________
Other Allergies: _______________________________________
Diet Restrictions
3. Parent/Minor Signature
This health history is correct so far as I know, and is up to date as of the last 90 days. The person herein described has permission to engage in all prescribed camp activities
except as noted. Emergency Authorization: I hereby give permission to the medical personnel selected by the camp officials to order x-rays, routine tests and treatment for me or
my child, as in the event I cannot be reached in an emergency. I hereby give permission to the physician selected by the camp director to hospitalize, secure proper treatment for,
and to order injection and/or anesthesia and/or surgery for me or my child as named above. I hereby give permission to transport me or my child for medical assistance. I hereby
give permission to Boy Scouts of America to use photos, likenesses, and images of me for marketing and publicity purposes. This form may be photocopied for use at camp. I
understand that I am responsible for payment of all medical treatments received from non-camp sources. I also give permission for the camp medical staff to administer
over-the-counter medications to my child, that the physician has approved on page 2 of this form.
I also give permission for my child to go on trips away from camp premises, and to participate in all camp activities.
***Signature of parent or guardian (or participant if over 18): _______________________________ Date: __________________
***Signature of Minor: ____________________________ Date: ___________________________
Revised 12/07

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