Class 1 Personal Health and Medical History
(Annually by all participants) For All Programs not exceeding 72 hours
IDENTIFICATION:
~To be filled out by a parent, guardian, or adult participant. Please print in ink.~
Name____________________________________________________________ Date of Birth___________________ Age_______ Sex ______
Name of parent or guardian_______________________________________________________________ Telephone_______________________
Home Address______________________________________________________City _______________________ State____ Zip ___________
Bus. Address ______________________________________________________City _______________________ State ____ Zip ___________
If person named above is not available in the event of an emergency, please notify:
Name ______________________________________________________Relationship _______________ Telephone ______________________
Name ______________________________________________________Relationship _______________ Telephone ______________________
Name of personal physician_______________________________________________________________ Telephone_______________________
Personal health/accident insurance carrier________________________________________________________ Policy No. __________________
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:
Asthma YES NO Diabetes YES NO High Blood Pressure YES NO
Cancer/Leukemia YES NO Heart Condition YES NO Kidney disease YES NO
Convulsions/siezures YES NO Hemophilia YES NO Other(explain) YES NO
Explain_______________________________________________________________________________________
List any medication to be taken at camp:_____________________________________________________________
List any physical or behavior 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 __________________ Pertussis _________________
Mumps _____________________ Polio ______________________ Diphtheria ______________________
Measles_____________________ Rubella _______________________
PARENT/GUARDIAN/ADULT AUTHORIZATION: This health history is correct so far as I know, and the person herein described has permission to engage in all BSA prescribed activities, except as noted by me. In the event of illness or accident in the course of such activity, I request that measures be instituted without delay as judgment 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 hospitalization, anesthesia, surgery, or injections of medication for my child (or for me, if and adult).

Signature of parent/guardian or adult __________________________________________________________Date___________________

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Class 1 Personal Health and Medical History
(Annually by all participants) For All Programs not exceeding 72 hours
IDENTIFICATION:
~To be filled out by a parent, guardian, or adult participant. Please print in ink.~
Name____________________________________________________________ Date of Birth___________________ Age_______ Sex ______
Name of parent or guardian_______________________________________________________________ Telephone_______________________
Home Address______________________________________________________City _______________________ State____ Zip ___________
Bus. Address ______________________________________________________City _______________________ State ____ Zip ___________
If person named above is not available in the event of an emergency, please notify:
Name ______________________________________________________Relationship _______________ Telephone ______________________
Name ______________________________________________________Relationship _______________ Telephone ______________________
Name of personal physician_______________________________________________________________ Telephone_______________________
Personal health/accident insurance carrier________________________________________________________ Policy No. __________________
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:
Asthma YES NO Diabetes YES NO High Blood Pressure YES NO
Cancer/Leukemia YES NO Heart Condition YES NO Kidney disease YES NO
Convulsions/siezures YES NO Hemophilia YES NO Other(explain) YES NO
Explain_______________________________________________________________________________________
List any medication to be taken at camp:_____________________________________________________________
List any physical or behavior 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 __________________ Pertussis _________________
Mumps _____________________ Polio ______________________ Diphtheria ______________________
Measles_____________________ Rubella _______________________
PARENT/GUARDIAN/ADULT AUTHORIZATION: This health history is correct so far as I know, and the person herein described has permission to engage in all BSA prescribed activities, except as noted by me. In the event of illness or accident in the course of such activity, I request that measures be instituted without delay as judgment 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 hospitalization, anesthesia, surgery, or injections of medication for my child (or for me, if and adult).

Signature of parent/guardian or adult __________________________________________________________Date___________________