Activity Name _____________________________________________________

For activity dating from _____________________ to _____________________

Scout's Name ______________________________________ Address _________________________________________

City ______________________________________ State _______ Zip _________________

Health/Accident Insurance Co. _________________________ Policy Number ___________________________________

__Asthma __Fainting Spells __Convulsions __Allergy to any medication, food __Any condition that may require

special care, medication

__Diabetes __Heart Trouble __Bleeding Disorders __plant, __animal, or __insect toxin

Explain: _____________________________________________________________________________________________

_____________________________________________________________________________________________________

_____________________________________________________________________________________________________

Check here if none of the above applies q

Have difficulty with (check if yes) __Eyes, ears, nose, throat __digestion __Bed-wetting __Lung __Sleep walking

Any condition now requiring regular medication?________________ Name of Medication______________

Any restriction of activity for medical reasons? Explain________________________________________________________

_____________________________________________________________________________________________________

_____________________________________________________________________________________________________

This health history is correct so far as I know, and the person herein described has permission to engage in all prescribed activities, except as noted by me. In the event I cannot be reached in an emergency, I hearby give permission to the physician, selected by the adult leader in charge, to hospitalize, secure proper anesthesia, or to order injection for my son.

I will not hold Boy Scouts of America or any of their representatives, including but not limited to, Adult members of Venturing Crew 369, Council Representatives, Sponsoring Institution,... liable for my son/daughter's actions.

Signature _____________________________________________________ Date __________________________________

Home Telephone Number _____________________ Telephone number of relative or neighbor ________________________

I authorize ONLY the following people to remove my son from the activity site:

Name Relationship

___________________________________________________________ _____________________________________

___________________________________________________________ _____________________________________

___________________________________________________________ _____________________________________

___________________________________________________________ _____________________________________

___________________________________________________________ _____________________________________

___________________________________________________________ _____________________________________