I. IDENTIFICATION  Age____ Sex ____   Date of Birth* ____/____/____

Name _______________________________________________________________
     Last Name                   First Name            Initials
Address ____________________________________________________________

City _______________________________ State _____  ZIP ______________

Health/Accident Insurance ______________________ Policy ____________

IN AN EMERGENCY NOTIFY:

Name ___________________________________ Relationship ______________

Address ________________________________ Home Phone ________________

City & State ___________________________ Business Phone ____________

Personal Physician _____________________ Phone _____________________

II. EMERGENCY MEDICAL INFORMATlON
Has or is subject to (check and give details):

_   Allergy to a medicine, food, plant, animal, or insect toxin.
_   Any condition that may require special care, medication, or diet.

O Asthma    O Convulsions     O Heart trouble       O Contact lenses
O Diabetes  O Fainting spells O Bleeding disorders  O Dentures

EXPLAIN _____________________________________________________________

_____________________________________________________________________

III. PARENTAL STATEMENT
Has it ever been necessary to restrict applicant’s activities
for medical reasons?  __No  __Yes, explain

_____________________________________________________
To the best of my knowledge, the information in sections
I, II, III, IV, and VI is accurate and complete. I request
licensed medical practitioner to examine applicant, to give
needed immunization, and to furnish requested information
to other agencies as needed. I give my permission for full
participation in BSA programs, subject to limitations noted
herein. 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.

Parent or guardian ______________________________________
                 (Must sign if applicant IS 18 or younger)

Applicant's signature ___________________________________

Date Signed _____/_____/_____

IV. IMMUNIZATIONS
If disease, put "D" and year.

         Last year                 Last year
           given                     given

Tetanus    ________     Mumps       ________
Diphtheria ________     Rubella     ________
Pertussis  ________     Polio       ________
Measles    ________     Chicken Pox ________

Religious Preference _______________________

V. Licensed Medical Practitioner's Evaluation And Advice

Aprroved for participation in:

O Hiking and Camping             O Winter Activities
O Competitive Sports             O All Activities

Specify exceptions _________________________________________________

Recommendations (explain any restrictions OR limitations:

____________________________________________________________________

____________________________________________________________________

Signed ___________________________________  MD/DO/DC/PA/RNP *
         Licensed medical practitioner        (Circle one)

Date ______/______/______

* Examinations conducted by licensed health care practitioners other
than physicians will be recognized for BSA purposes in those states
where such practitioners may perform physical examininations within
their legally prescribed scope of practice.

VI. Medical History
Parent (or applicant if 18 or older): Fill in sections I, II, III, IV, and VI before seeing licensed medical practitioner. Check immunizations to be given at this time. Be sure to include any emergency information and restrictions or special care that should be ovserved. Especially be sure to record any injuries, illnesses, surgery, or significant changes in condition of health of applicant since last complete examination.

Date of most recent complete physical examination (month and year) ___________________
Are you aware of any current health problems? ( ) No, ( ) Yes
Now under medical care or taking medicines? ( ) No, ( ) Yes
Has there been any surgery, injury, illness, allergy, or change in health status since last complete physical examiniation? ( ) No, ( ) Yes

Give dates and full details below for any 'yes' answers.

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