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 Venture Crew 423

Native American Camporee

Estell Manor, NJ

Class 1 Medical

Name: __________________________ Age: _______ Sex: ______

Address: _______________________________________________

City: _________________________State: ______ Zip: _________

Troop #: _______Leader Name: ___________________________

IN AN EMERGENCY NOTIFY: __________________________

Relationship: ____________________ Phone 1: ______________

                                                                 Phone 2:_______________

OTHER EMERGENCY CONTACT: ______________________

 RELATIONSHIP: _______________ Phone 1: ______________

                                                                 Phone 2: ______________

Emergency Medical Information:            MEDICATIONS TAKEN:

Allergies: ____________________             ______________________

Asthma: _____________________             ______________________

Convulsion: __________________             ______________________

Heart Trouble: _______________             ______________________

Diabetes: ____________________             ______________________

Corrective Lenses: ____________             ______________________

Fainting: ____________________

Dentures: ____________________

ADHD: ______________________

OTHER: ____________________

HEALTH CARE PROVIDER:

Name: ______________________ Phone: _________________

Health Coverage: _____________________________________

IF Minor, Signature of Parent or Guardian:

X____________________________________ Date: ___________