Cub Scout Day Camp Health Form - Boy Scouts Of America
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1Cub Scout Day Camp Health Form
(Required for “ALL” youth & adults attending camp.)
To be filled out by parent, guardian, or adult participant. Please print in ink.
IDENTIFICATION
Name___________________________________________ Date of birth_____________ Age________ Sex_______
Name of parent or guardian_________________________________________________________________________
Home Phone____________________ Business Phone____________________ Cell Phone_____________________
Home address_______________________________ City________________________ State_______ Zip_________
Business address_____________________________ City________________________ State_______ Zip_________
If person named above is not available in the event of an emergency, notify:
st
1
Contact - Name_____________________________ Relationship_________________ Telephone______________
nd
2
Contact – Name_____________________________ Relationship_________________ Telephone______________
Name of personal physician___________________________________________________ Telephone_____________
Personal health/accident insurance carrier________________________________________ Policy #_______________
I give permission for full participation in BSA programs, subject to limitations noted herein:
In case of emergency, I understand every effort will be made to contact me (if participant is an adult, my
spouse or next of kin). In the event I cannot be reached, I hereby give my permission to the licensed health-
care practitioner selected by the adult leader in charge to secure proper treatment, including hospitalization,
anthesthesia, surgery, or injections of medication for my child (or for me, if participant is an adult).
Date_________________ Signature of parent/guardian or adult___________________________________
Some hospitals require the parent/guardian signature to be notarized. Check with your BSA local council.
Check all items that apply, past or present, to your health history. Explain any “yes” answers.
Yes r
No r
ALLERGIES: Food, medicines, insects, plants, other:
Explain: _____________________________
_________________________________________________________________________________________________
GENERAL INFORMATION:
Yes No
Yes No
Yes No
r r
r r
r r
ADHD
Convulsions/seizures
Hemophilia
r r
r r
r r
Asthma
Diabetes
Kidney disease
r r
r r
r r
Cancer/leukemia
Heart trouble
Other
Explain: _________________________________________________________________________________________
________________________________________________________________________________________________
Please list ALL medications taken in the 30 days prior to arrival at the Scouting activity where this form is to be used:
________________________________________________________________________________________________
List any medications to be taken at camp: _______________________________________________________________
List any physical or behavioral conditions that may affect or limit full participation in swimming, backpacking, hiking long
distances, or playing strenuous physical games: __________________________________________________________
List equipment needed, such as wheelchair, braces, glasses, contact lenses, etc.: _______________________________
Immunizations: (Give date of last inoculation.)
Tetanus toxoid _____________________
Measles ____________________
Polio ____________________
Diptheria
_____________________
Mumps ____________________
_________________________
Pertussis
_____________________
Rubella ____________________
_________________________
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