Cub Scout Pack 802 CLASS 1 Personal Health and

							Cub Scout Pack 802 Registration
Class 1 Personal Health and Medical History
     1.    Please complete this form or mark any changes
     2.    New Scouts only – Please Also Complete the “Application to Join a Pack”
                                                                                                                                            www.pack802.org
     3.    Make check out to Pack 802
Registration fee is $75 per scout. If you will be a Den Leader or Pack Officer and have turned in an Adult Application,
your scout receives a discount rate of $40.
Questions? Contact Tat Huen (925) 648-9136 or tat@pack802.org.


Scout First Name                         Last Name                                     Date of Birth                Age      Sex     Phone
                                                                                                                             M

Rank in Sept school year                                                                                                                              Den Number
             st                           nd                          rd                             th                               th
     Tiger (1 Grade)              Wolf (2 Grade)              Bear (3 Grade)            Webelos I (4 Grade)             Webelos II (5 Grade)

Email Contact Name                                        Email Address (Please Print clearly)


Name of Parent or Guardian #1                             Day Phone                              Evening Phone                       Cell Phone


Name of Parent or Guardian #2                             Day Phone                              Evening Phone                       Cell Phone


Home Address


Emergency Contact #1 (someone other than Parent or Guardian)                                     Relationship                        Phone


Emergency Contact #2                                                                             Relationship                        Phone


Personal Physician                                                                                                                   Phone


Personal Health/Accident Insurance Carrier                                                       Policy Number


I give permission for full participation in Boy Scouts of America (BSA) programs, subject to limitations noted herein. In case of emergency, I understand every
effort will be made to contact me (if participant is an adult, my spouse or next of kin.) In the event I cannot be reached, I hereby give my permission to the licensed
health-care practitioner selected by the adult leader in charge to secure proper treatment, including hospitalization, anesthesia, surgery, or injections of medication
for my child (or for me, if participant is an adult.)
Photo (Talent) Release: I hereby assign and grant to the BSA and Pack 802 the right and permission to use and publish the photographs/film/videotapes/electronic
representations and/or sound recordings made during Pack activities (Den meetings, Pack meetings, outings, camporees, sleep-ins, picnics and hikes), and I hereby
release the BSA and Pack 802 from any liability from such use and publication. I hereby authorize the reproduction, sale, copyright, exhibit, broadcast, electronic
storage and/or distribution of said photographs/film/videotapes/electronic representations and/or sound recordings without limitation at the discretion of the BSA
and Pack 802 and I specifically waive any right to any compensation I may have for any of the foregoing.
Date                             Signature of Parent/Guardian to accept the conditions stated above
                                 X

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Scout First Name                            Last Name



Check all items that apply, past or present, to your health history. Explain any “Yes” answers.

ALLERGIES: Food, medicines, insects, plants                     Yes        No       Explain:

GENERAL INFORMATION: Yes                                No                                 Yes   No                              Yes      No
                ADHD                                                Convulsions/Seizures                          Hemophilia
   (Attention-Deficit Hyperactivity Disorder)
                                  Asthma                                        Diabetes                High Blood Pressure

                    Cancer/Leukemia                                       Heart Trouble                       Kidney Disease
Explain:


Please list ALL medications taken in the 30 days prior to arrival at the Scouting activity where this form is to be used:


List any medications to be taken at camp:


List any physical or behavioral conditions that may affect or limit full participation in swimming, backpacking, hiking long
distances, or playing strenuous physical games:


List equipment needed such as wheelchair, braces, glasses, contact lenses, etc.:


Immunization: (Give date of last inoculation.)
 Tetanus toxoid                                               Measles                                   Polio
      Diphtheria                                               Mumps
        Pertussis                                             Rubella



                                                         TOUR PERMIT INFORMATION
Boy Scouts of America require that the information requested below be included with all tour permits submitted for outings (over
5 miles) by Pack 802. This will expedite the paperwork process.
Driver Name #1                                  Driver License #1                Driver Name #2                 Driver License #2


Year Make and Model of Vehicle #1                                                License Plate #1               Number of Seatbelts #1


Year Make and Model of Vehicle #2                                                License Plate #2               Number of Seatbelts #2


All vehicles MUST be covered by a public liability and property damage liability insurance policy. The amount of this coverage must meet
or exceed the insurance requirement of the state in which the vehicle is licensed. (It is recommended, however, that coverage limits are at least
$50,000/$100,000/$50,000 or $100,000 combined single limit.) Any vehicle carrying 10 or more passengers is required to have limits of
$100,000/$500,000/$100,000 or $500,000 combined single limit. Please indicate your coverage amount for Liability Each Person / Liability
Each Accident / Property Damage, or that you exceed the indicated requirements.




de7dd051-baef-4e4c-b6ce-4df8b37e6e4e.doc – Last saved 1/11/2010 3:16:00 PM                                                                     2 of 2