Adult Health History Form

Adult Health History Form

This health history form is confidential, and is to be completed and signed by adult members.
Name*

First NameLast Name
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Troop Number
Troop Position
Leader, Helper, etc.
Social Security Number
Home Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Emergency Contact
In case of emergency, please notify:*

First NameLast Name
Relationship to adult:*
Emergency Contact Phone Number:*
Please enter a valid phone number.
Emergency Contact Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Signature
This health history is complete and accurate. I am able to engage in all prescribed activities except as noted.
Signature*

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Date Signed*

MonthDayYear
Date
Should be Empty:

	Year Primary Series Completed	Year of Last Booster
Diptheria
Pertussis (whooping cough)
Tetanus
TD
Measles
Other

Emergency Contact