Participant Health Record and Medical Release

Captures a participant's medical history alongside emergency contacts, insurance details and a signed treatment authorization. Sections cover allergies, ongoing conditions, immunizations and current medications. Troop leaders and camp staff keep the clinical picture on hand before every outing.

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Page 1

Part I. Participant details

Name

Date of birth

Phone number

Address

City, state and ZIP code

Troop number

Who has custody of the participant?

Mother's or guardian's name

Address (if different from the participant's)

Employer

Occupation

Daytime phone

Evening phone

Mobile phone

Email

Father's or guardian's name

Address (if different from the participant's)

Employer

Occupation

Daytime phone

Evening phone

Mobile phone

Email

Part II. Emergency contacts

Name

Relationship to the participant

Address

Dirección

Ciudad

Estado / Provincia

Código postal

Home phone

Work phone

Mobile phone

Name

Relationship to the participant

Address

Dirección

Ciudad

Estado / Provincia

Código postal

Home phone

Work phone

Mobile phone

Adults authorised to collect the participant

Name

Relationship to the participant

Name

Relationship to the participant

Physician's name

Phone

Address

Dirección

Ciudad

Estado / Provincia

Código postal

Dentist's name

Phone

Address

Dirección

Ciudad

Estado / Provincia

Código postal

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Page 2

Part IV. Allergies: tick everything that applies

Details of the allergic reactions

Describe each allergy ticked above, the reaction it causes and any activity to encourage or restrict

Part V. Other health conditions: tick everything that applies

Asthma Diabetes Seizures Heart condition Attention disorder Anxiety or depression Vision or hearing difficulty None

Explain each condition ticked above and what supervising adults should keep in mind

Which of these illnesses has the participant had?

Part VI. Current medication

Any other medication we should know about

Authorisation for emergency medical care

Health insurance details

Parent or guardian signature

Sign here

Date

Is the participant covered by a family health plan?

Yes No Not sure

Insurer or plan name

Policy or group number

Name of the policyholder

Relationship to the participant

Insurance ID number

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