Site hosted by Angelfire.com: Build your free website today!

Scouts Canada

 

Physical Fitness Certificate

 

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 parentís/guardianís 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:†††††††††††††††††††††††

Physicianís 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 Yeso 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 applicantís activities for medical reasons? o Yeso No

Details:†††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††

 

Signed, Parent/Guardian:†††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††† Date:††††††††††††††††††††††††††††

Updated, Parent/Guardian:††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††† Date:††††††††††††††††††††††††††††

Updated, Parent/Guardian:††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††† Date:††††††††††††††††††††††††††††