| HEALTH FORM | ||
| Name___________________________ | Birthdate___/___/___ | Pack or Troop #___ |
| Address____________________________________________ | District Northwest | |
| City______________________________ | State____________ | ZIP____________ |
| IN CASE OF EMERGENCY NOTIFY: | ||
| Name___________________________ | Relationship: Parent Guardian Other_____ | |
| Address____________________________________________ | Other__________ | |
| City______________________________ | State____________ | ZIP____________ |
| Phone____________________________ | Other Instructions:___________________ | |
| (Area Code & Number) | ||
| Personal Health Insurance Carrier__________________________________________ | ||
| Group No._________________________ | ID No.____________________________ | |
| Address for Claims_____________________________________________________ | ||
| Policy Holder's Name____________________________________________________ | ||
| In case of emergency, I understand every effort will be made to contact me. 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, and injections of medication, for my son. | ||
| Date:________________ Signature of Parent or Guardian:_____________________ | ||
| HEALTH HISTORY | ||
| HAVE OR ARE SUBJECT TO: (check if yes) | ||
| HAVE DIFFICULTY WITH: (check if yes) | ||
| Name of medication_____________________________________________________ | ||
| ____________________________________________________________________ | ||
| This health history is correct so far as I know. | ||
| Signature___________________________________ Date___________ | ||
| (Parent/Guardian if under 18, otherwise Adult's signature) | ||