Lodge 70 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:___________________________________________________________________

EMERGENCY CONTACT INFORMATION:
Name of Parent/Guardian or emergency contact: _______________________________________
Telephone:_____________________________ Alternate Telephone: _____________________
Secondary emergency contact: Name: ______________________________________________
Relationship:___________________________ Telephone: _____________________________

PHYSICIAN & INSURANCE INFORMATION::
Name of personal physician: ____________________ Telephone: _________________________
Personal health/accident insurance carrier: ____________________________________________
Policy Number: _______________________________________________________________

HEALTH HISTORY:
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

O

O

Heart Trouble

O

O

Back/Spinal Problems

O

O

High Blood Pressure

O

O

Convulsions/Seizures

O

O

Orthopedic Problems

O

O

Diabetes

O

O

Respiratory Problems

O

O

Explain: ________________________________________________________________________

List any medications currently taken: ___________________________________________________
List any other health concerns: ________________________________________________________
Immunizations: Date of last tetanus Toxoid: ______________________________________________

PERMISSION:
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: _______________________________

Note: A Lodge 70 Medical Form MUST be included with every Lodge event! These can be mailed with the Registration Form for the event or brought along with the participant.