Aquila District Cub Scout Day Camp Registration

Tuesday, July 20th
through
Friday, July 23rd
Schoenwald Park

Youth Day Camp Registration & Health History

Please follow ALL three steps below to register for the 2010 Aquila District Cub Scout Summer Day Camp. If you are unsure whether the youth you are registering is eligible for the Tag-along program, please read the "Day Care" section on the Details page.

Step 1. Fill out the fields below with information for the youth you are registering.

Class One Activity:

Day camp, overnight hike, swimming party, or other programs not exceeding 72 hours, with level of activity similar to that of home or school. Medical care is readily available. Current personal health and medical summary (history) is attested by parents to be accurate. The form is filled out by all participants and is on file for easy reference.

Your Contact Information:

Name: Phone:

E-Mail Address:

Youth Identification:

Name:

Address:

City: State: Zip:

Phone: Date of Birth: (MM/DD/YYYY)

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:

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. 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.

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.