ArrowHEADS Medical Form

To be filled out by Parent/Guardian or Adult participant. Please print in ink.

IDENTIFICATION:

Name: Date of birth: Age: Sex:

Address: City:

State: Zip: Telephone:

Name of Parent/Guardian or emergency contact:

Telephone: Alternate Telephone:

Secondary emergency contact: Name:

Relationship: Telephone:

Name of personal physician: Telephone:

Personal health/accident insurance carrier:

Policy Number:

Check all items that apply, past or present, to your health history. Explain any "Yes" answers.

Allergies: Food, medicines, insects, plants Yes No

Explain:

General Information: Yes No Yes No

Asthma ¨ ¨ Heart trouble ¨ ¨

Back/spinal problems ¨ ¨ High blood pressure ¨ ¨

Convulsions/seizures ¨ ¨ Orthopedic problems ¨ ¨

Diabetes ¨ ¨ Respiratory problems ¨ ¨

Explain:

List any medications currently taken:

Immunizations: Date of last tetanus Toxoid:

I give my permission for full participation in BSA programs, subject to limitations noted herein. In the event of illness or accident in the course of such activity, I request that measures be instituted without delay as the judgement of medical personnel dictates.

In case of emergency, I understand every effort will be made to contact me (if an adult, my spouse or next of kin). In the event, I cannot be reached, I hereby give my permission to the physician selected by the adult leader in charge to secure proper treatment, including but not limited to hospitalization, anesthesia, surgery, or injections of medications for my child (or for me, if an adult)

Signature of parent/guardian or adult participant:

Date: