• ATTENTION:

    Please review the document and understand what you are signing.  This is a legal document.

    Please fill out the form as completely and accurately as possible (not just the required fields).

    Make sure you have your immunization records, insurance information, and primary doctor's information on hand before you start!

  • Pathfinder Personal Information

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  • Health History | Past and Current

    Please select all that apply
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  • Allergies/Allergic Reactions

    Please fill out each section that the Pathfinder has had known allergic reactions with and tell what happened:
  • Additional Medical Information

  • Immunization History

  • Please select all applicable vaccines as well as their corresponding dates as best as possible.

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  • Emergency Parental Contact Information

  • Alternate Contact #1 (if parent is unavailable)

  • Alternate Contact #2 (if parent is unavailable)

  • Doctor to Consult in Case of Emergency

  • Medical Insurance

  • PARENT'S AUTHORIZATIlON-required for those under 18 years of age or under 21 if still living at home.
    This health history is correct so far as i know, and the child named above has permission to engage in all activities, except as noted herein by me. Exceptions (if any)  . In the event I cannot be reached in an emergency, I hereby give permission to the medical provider selected by the adult leader in charge to hospitalize, secure proper anesthesia, or to order injections or surgery for my child. A photo copy of this shall be as valid as the original.

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