Fillable Boy Scout Medical Form printable pdf download

Boy Scouts of America — Troop 7

B. S. A. Troop #7

PO Box 621

Scituate, MA 02066

MEDICAL FORM

Scout’s

______________

Name: ____________________________________ E Mail _______________________________ Cell Phone

Parent’s Information:

PLEASE PRINT

Name________________________________________________ Name ________________________________________________

Address ______________________________________________ Address ______________________________________________

City __________________________ State ____ Zip _________ City __________________________ State ____ Zip _________

Home Phone________________ Cell Phone ________________ Home Phone________________ Cell Phone ________________

Work Phone _____________________________ Ext _________ Work Phone _____________________________ Ext _________

E Mail _______________________________________________ E Mail _______________________________________________

Emergency Contact:

Doctor’s Information:

Name________________________________________________ Name of Practice _______________________________________

Address ______________________________________________ Doctor’s Name_________________________________________

City __________________________ State ____ Zip _________ Address ______________________________________________

Home Phone _______________ Cell Phone ________________ City __________________________ State ____ Zip _________

Work Phone _____________________________ Ext. ________ Office Phone _______________ Office Fax _________________

E Mail _______________________________________________ E Mail _______________________________________________

Relationship __________________________________________ Notes

DATE OF LAST TETANUS SHOT

DATE OF BIRTH

Are there any allergies or medical conditions of which we should be aware?

None

What medication, if any, does your child take on a regular basis?

None

In case of emergency, my son___________________________________________________________may receive necessary first aid

treatment, receive medical treatment by a duly licensed physician and/or be admitted to a hospital in case of emergency. This remains in

effect for the following calendar year ___________ or the following dates: _______________________________________________

Parent’s Signature:

____________________________________________________

Date _______________________________

Insurance Co. __________________________________ Phone ____________________ Policy Number______________________

Name of Insured________________________________________________________

__________________ ________________

Please keep this information updated with the troop.

CLEAR

FORM 02 (11/11)

Boy Scout Medical Form