Adult Health History Form

Adult Health History Form

This health history form is confidential, and is to be completed and signed by adult members.
Troop Use (Troop Camping, Camporee, etc)Camp 2gether (GSSEF Overnight Camp)
Name*

First NameLast Name
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
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.Format: (000) 000-0000.
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*

Clear
Date Signed*

MonthDayYear
Date
YesNo
Troop Leader email
example@example.com
Should be Empty:

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

Emergency Contact