Gemstone District Cub Scout Day Camp June 15 – 19, 2015 Read

Gemstone District Cub Scout Day Camp
June 15 – 19, 2015
Youth Application/Health Form
Cost $70.00 (an additional late fee of $10 if received after May 25)
!!! NO APPLICATIONS ACCEPTED AFTER JUNE 8 !!!
Read this form carefully!
A boy will not be permitted to participate in the Day Camp unless this form is completely filled out and the
parent or guardian gives written approval by signing below. Mail this form, along with a check made
payable to Piedmont Council, BSA, to: Cindy Bell P.O. Box 94 Mount Mourne, NC 28123
Please print:
Name___________________________________________________
DOB___________________ Current Grade______ Pack #_______Rank at time of camp__________
Address_________________________________________________
(Wolf, Bear or Webelos)
City_____________________________ State______ Zip:_________
Phone (Home)____________________ (Work)______________________ (Cell)____________________
Email (please print) ___________________________________________________________________
Health History:
Family physician_________________________________________ Phone_________________
Have or is subject to: (check if yes)
______Asthma
______Carries inhaler
______ Heart Trouble
______Sports Restriction
______Diabetes
______Convulsions
______Fainting Spells
______Allergic Reaction (please specify)____ __________________________________________________
______Carries Epipen
Other (Describe in detail)___________________________________________
______Check here if none of the above applies.
Has Cub Scout had a recent DPT injection?________ When? ____________________________
Family Health Insurance Info: (Company)_____________________________ (Policy#)______________________
Other Instructions:__________________________________________________________________
_______________________________________________________________________________
Person authorized to pick up child__________________________________________________
In case of emergency notify:
Name_________________________________________________ Relationship_____________
Phone (Home)____________________ (Work)______________________ (Cell)_____________________
Parent Authorization:
This Health History is correct so far as I know, and the person (Cub Scout) herein described has permission to engage in all prescribed
activities, except as noted by me in Other Instructions above. In the event I cannot be reached in an emergency, I hereby give
permission to the physician, selected by the adult leader in charge, to hospitalize, secure proper anesthesia, and/or to order injection
for my son.
Signature_________________________________________________________________________________________________
Parent or Guardian
Date
Home #
Cell#
If your schedule permits, and you would like to work, check here: Yes______ No_______
Included in your child’s registration fee is one (1) T-shirt. This year you will be able to order your son’s T-shirt size, PLEASE,
make your one (1) selection carefully as this will be the size given to your child. Consider one size bigger for him to grow
into.
____ Youth - Medium
____ Youth - Large
____ Adult - Small
____ Adult - Large
____ Adult – X Large
____ Adult – 2X Large
____ Adult - Medium
You will not be able to pre-order additional shirts so PLEASE do not send any extra money; there will be extra T-shirts
available at camp registration days on a first come first served basis.
For T-shirt questions contact Melba Ritchie 704-878-0628
Your son needs to bring a BACKPACK/BOOKBAG each day to carry his water bottle and items collected at program
sessions. He also needs to bring a bottle of water each day.