(Annually by all participants)
To be filled out by parent, guardian, or adult participant. Please print in blue ink.
A Class 1 record is required annually for all participants. Includes any event that does not exceed seventy-two consecutive hours, where the level of activity is similar to that normally expended at home or at school, and where medical care is readily available. Examples: day camp, day hike, swimming party, or an overnight camp. Medical information required is a current health history signed by parents or guardian. This form is filled out by participants and kept on file for easy reference.
IDENTIFICATION Name _______________________________________________ Date of birth ___________________ Age ____ Sex ____ Name of parent or guardian ____________________________________________ Telephone _______________________ Home address __________________________________ City ________________________ State _____ Zip ___________ Business address ______________________________ City ________________________ State _____ Zip ___________ If person above is not available in the event of an emergency, notify Name __________________________________ Relationship __________________ Telephone _______________________ Name __________________________________ Relationship __________________ Telephone _______________________ Name of personal physician ____________________________________________ Telephone _______________________ Health/accident insurance carrier _________________________________ Policy/patient No____________________ Check 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 Yes No Asthema ( ) ( ) Diabetes ( ) ( ) High blood pressure ( ) ( ) Cancer/leukemia ( ) ( ) Heart trouble ( ) ( ) Kidney disease ( ) ( ) Convulsions/seizures ( ) ( ) Hemophilia ( ) ( ) ( ) ( ) Explain: ________________________________________________________________________________________________ List any medications to be taken at camp: _______________________________________________________________ List any physical or behaviorial 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, contacts, etc.: _______________________________________________ IMMUNIZATIONS: (give date of LAST inoculation or booster) Tetanus toxoid _______________________ Measles _______________________ Polio ______________________ Diptheria _______________________ Mumps _______________________ Others ______________________ Pertussis _______________________ Rubella _______________________ ______________________ Date _______________ Signature of parent/guardian or adult _____________________________________________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 an adult).
Some hospitals require that the parent/guardian signature be notarized. Check with your BSA local council.
BSA form 34414 modified.