Name ________________________________________________________________ Date of Birth _____________

Address ____________________________________________________   Unit Number_____     Youth __ Adult __

City ____________________________________________________________ State _________ Zip ___________

Family Medical Insurance Co. ______________________________________ Policy Number _______________

In Case of Emergency, Notify:
Name ___________________________________________________________ Relationship ___________________

Address _________________________________________________________________________________________

Home Phone ____________________ Cell Phone / Pager ____________________ Other ___________________

Special Instructions ____________________________________________________________________________

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Health History To be completed and signed by parent / legal guardian for participants under 18 years of age, or by adult participant for themselves.

Have had or subject to: (Check if Yes)
___ Frostbite	___ Tuberculosis	___ Rheumatic Fever
___ Hypothermia	___ Fainting Spells	___ Sinus Trouble
___ Earache / ear infection	___ Epilepsy	___ Allergy or reaction to any medication
___ Asthma	___ Convulsions	___ Severe Stomachaches
___ Heart Trouble	___ Diabetes	___ Other __________________________
Please describe any marked items _____________________________________________________________________________________________________
Have diffaculty with: (Check if Yes)
___ Eyes, ears, nose, throat	___ Digestion	___ Bed-wetting
___ Lungs, breathing	___ Sleepwalking	___ Menstrual Problems (females)
___ High Blood Pressure	___ Headaches	___ Nervous Condition
Have had: (Check if Yes)
___ Measles	___ Chicken Pox
___ Mumps	___ Whooping Cough
Any condition(s) now requireing regular medication? __ Yes __ No Medication(s): ______________________________________________________________
__________________________________________________________________________________________________________________________________
Note: Please include the names of all medications, as well as their instructions and prescribed dosages.
Any Any restrictions of activity for medical reasons? Please explain: ________________________________________________________________________
Please list any allergies (food, medication, etc.): _____________________________________________________________________________________

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Information above is correct to the best of my knowledge. Furthermore, I meet the age requirements for the program I will be participating in.

Participants Signature _____________________________________________________________________________ Date _________________________

Parents Authorization - Required for those under 18 years of age.
This health history is correct so far as I know, and the person herin described has permission to engage in all prescribed activities, except as noted. In the event I can not be reached in an emergency, I herby give permission to the physician, selected by the adult leader in charge, to hospitalize, secure proper anesthesia, or to order injection or surgery for my minor child.

Parent or Legal Guardian Signature ___________________________________________________________________Date ________________________