Scouts Canada
|
Note: |
This form is to be filled out by the parent/guardian at the beginning of each Scouting year and kept by the leader. It is the parent’s/guardian’s responsibility to update the leader of any changes in the medical condition of the child/ward throughout the Scouting year. This
form should be filled out for adults as well. |
Surname: Given Name: Initial: Date
of Birth: Age:
o
Male o Female
Address: City:
Province: Postal
Code: Home
Phone:
Physician’s
Name: Scout
Group Name:
Provincial
Medical Plan Number: Insurance
Coverage Held:
Emergency
Medical Information:
Does the applicant have any allergies: o Yes
o
No
|
o
Medicine |
o
Insect Bites |
o
Toxins |
o
Food |
o
Smoke |
|
o
Plants |
o
Animals |
o
Other |
|
|
|
Details:___________________________________________________________________________________________ |
||||
Has had, please check (x)
|
o
Appendicitis |
o
Mumps |
o
Chicken Pox |
o
Measles |
o
Kidney Disease |
|
o
Scarlet Fever |
o
Rheumatic Fever |
o
Heart Condition |
o
Other:_____________________________ |
|
If subject to any of the following, check
(x) and give details:
|
o
Asthma |
o
Contact Lenses |
o
Headaches |
o
Fainting Spells |
o
Bleeding Disorders |
|
o
HIV |
o
Ear Problems |
o
Diabetes |
o
Hernia |
o
Back Problems |
|
o
Motion Sickness |
o
Cramps |
o
Convulsions |
o
Sleepwalking |
o
Nightmares |
|
o
Bed Wetting |
o
Pregnant |
o
Other:__________________________________________________ |
||
|
Details:___________________________________________________________________________________________ |
||||
Has
the participant menstruated? o Yes o
No If no, has she had menstruation
explained to her? o Yes
o
No
Does the participant require special care,
medication or diet?
Details:
Date of most recent physical examination
(Month and Year):
Date of last tetanus shot (Month and Year):
Swimming Ability: o Non-Swimmer o Swimmer
Highest Level Achieved:
Has it ever been necessary to restrict the
applicant’s activities for medical reasons? o Yes o No
Details:
Signed, Parent/Guardian: Date:
Updated, Parent/Guardian: Date:
Updated, Parent/Guardian: Date:
