Your Contact Information:

Name: Phone:

E-Mail Address:

Scout Identification:

Name:

Address:

City:  State:  Zip:

Phone:  Date of Birth: (MM/DD/YYYY)

Pack #:  Grade completed this June: 1st 2nd 3rd 4th

I am applying for a Campership (If checked, complete a Campership form)

Each Cub Scout Pack must provide one adult volunteer per five youth (minimum of two adults per Pack). List the adult who is contributing to your Pack's one-to-five ratio for this Scout, and be sure to complete a registration/health form for this adult:

Make sure all volunteers attend the Day Camp Training!

Emergency Information:

Parent/Guardian:   Relationship:

Phone During Day Camp:   Mobile Phone:

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

Name:   Relationship:

Phone During Day Camp:   Mobile Phone:

Name of personal physician:   Phone:

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

Designated Guardians

In addition to the emergency contacts listed above, the following people have my permission to pick up this Scout after day camp or during day camp in case of an emergency.

Name: Phone:

Name: Phone:

Name: Phone:

Name: Phone:

Name: Phone:

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. The youth described herein has my permission to engage in all prescribed activities except as noted above by me. In case of emergency, I understand every effort will be made to contact me. 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 for my child. (The signature below must be dated within six months of attendance at camp.)

Signature of parent/guardian: _____________________________ Date: ___________

(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 with your payment.

Enclose: Day camp fee (click this link for details). Make checks payable to B.S.A.

Check #

Credit Card # (write on this form after you print it)

Visa/Mastercard __ __ __ __   __ __ __ __   __ __ __ __   __ __ __ __
Exp ___/___

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.