Identification:

Name:

Address:

City:  State:  Zip:

E-Mail Address:

Phone:  Date of Birth: (MM/DD/YYYY)

Pack or Troop #:

Volunteer Days:

Please check all of the days this person will be volunteering at camp:

    Tuesday    Wednesday    Thursday    Friday

Please select the Day Camp Training this person will attend prior to camp:

    Option 1: Thursday, July 10th from 6:30pm to 8:30pm

    Option 2: Saturday, July 12th from 10am to 12pm

    Option 3: Attended day camp training last year

Emergency Information:

Spouse/Next of Kin:

Phone During Day Camp:   Mobile Phone:

In the event of an emergency if person named above is not available, please notify:

Name:

Phone During Day Camp:   Mobile Phone:

Name of personal physician:   Phone:

Pack or Family health/accident insurance co:   Policy #:

Health History: (Check all items past or present that apply.)

ADD/ADHD
Asthma
Diabetes
Convulsion/seizure
Restriction of activities for physical, behavioral, or other reasons
Heart trouble
Hemophilia
High blood pressure
Kidney disease
Allergies (food, plants, insects, medicine, bee stings, etc.)

Explain all checked answers:

Immunizations: (Give date of last inoculation or date of occurrence of disease.)

TDP:  Polio  MMR (MM/DD/YYYY)

Medications: (List those to be taken at camp. Medications must be in original bottle.)

The medical information provided by me above is correct to the best of my knowledge. In case of emergency, I understand every effort will be made to contact spouse/next of kin. In the event I cannot be reached, I hereby give my permission to the physician selected by the adult leader in charge to secure proper treatment, including hospitalization, anesthesia, surgery, or injections of medication. (The signature below must be dated within six months of attendance at camp.)

Signature: _____________________________ Date: ___________
(If attendee is under 18, parent or guardian must sign.)

(Initial) _______ I further give consent for photographs/videos depicting camp participant named above in day camp activities to be used by the Boy Scouts of America.

Step 2. Print this completed form, make sure it is signed, and send it in.

Mail to:
   Chief Seattle Council
   Aquila District Cub Day Camp, Attn: D. Gelis
   3120 Rainier Avenue S
   Seattle, WA 98144-6095

Step 3. Click the Register button below to e-mail your registration information to the event coordinators.