Adult Health History Form

Adult Health History Form

This health history form is confidential, and is to be completed and signed by adult members.
Purpose of Form
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
Date Signed

MonthDayYear
Date
Would you like a copy of this form emailed to your Troop Leader?
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