Member/Participant Health and Medical Record

Participant's Name *
Participant's Name
Date of Birth *
Date of Birth
Address *
Address
Emergency Contacts:
Mother's Name *
Mother's Name
Father's Name *
Father's Name
Contact Name *
Contact Name
Other contact if parrents cannot be reached:
Health/Accidental Insurance Information:
Please Check One *
Health/Accident Insurance Company
Effective Date
Effective Date
Physicians Information
ALLERGIES
Health History
Asthma *
Diabetes *
Hypertension (high blood pressure) *
Heart disease/heart attack/chest pain/heart murmur *
Stroke/TIA *
Lung/Respiratory Disease *
Ear/Sinus Problems *
Muscular/Skeletal Condition *
Psychiatric/psychological and emotional difficulties *
Behavioral/neurological disorders *
Bleeding disorders *
Fainting spells *
Thyroid disease *
Kidney disease *
Sickle cell disease *
Seizures *
Sleep disorders (e.g., sleep walking, sleep apnea) *
Use CPAP? *
Abdominal/digestive problems *
Surgery *
Date of Surgery (if applicable)
Date of Surgery (if applicable)
Serious injury *
Excessive fatigue or shortness of breath with exercise *
IMMUNIZATIONS
The following immunizations are recommended. Tetanus immunization is required and must have been received within the last 10 years.
Tetanus *
Pertussis *
Diphtheria *
Measles *
Mumps *
Rubella *
Polio *
Chicken Pox *
Hepatitis A *
Hepatitis B *
Meningitis *
Influenza *
Exemption to Immunizations Claimed (form required)
Medications
Medications Needed? *
Bring enough medications in sufficient quantities and in the original containers. Make sure that they are NOT expired, including inhalers and EpiPens. You SHOULD NOT STOP taking any maintenance medication unless instructed to do so by your doctor.
ADULTS AUTHORIZED TO TAKE YOUTH TO AND FROM EVENTS:
You must designate at least one adult. Please include a telephone number.
Name *
Name
Name
Name
Name
Name
I understand that, if any information I/we have provided is found to be inaccurate, it may limit and/or eliminate the opportunity for participation in any event or activity.
I give permission for full participation in Trail Life USA activities, except where specifically limited in writing herein. ThisHealthandMedicalRecordiscorrectandcomplete,asfarasIknow. IherebygivepermissionforTrailLifeUSAleadershiptoadminister prescribed and noted over the counter medications. Incaseofemergency,Iunderstandeveryeffortwillbemadetocontactme. IntheeventthatIcannotbereached,Iherebygivemypermissionto the licensed health-care provider selected by the Trail Life USA adult leader(s) to secure proper treatment, including related transportation, hospitalization, anesthesia, surgery, or injections of medication for my child, except as noted below. I agree to the release of records necessary for treatment.
Signatures
AGREEMENT: By entering text in the below, "signature" field, I agree that my electronic signature is the legally binding equivalent to my handwritten signature. Whenever I execute an electronic signature, it has the same validity and meaning as my handwritten signature. I will not, at any time in the future, repudiate the meaning of my electronic signature or claim that my electronic signature is not legally binding.
Date of Signature *
Date of Signature
Date of Signature *
Date of Signature
Date of Signature
Date of Signature
If we need to know anything else, please use this area for that.