Youth Emergency Information, Medical Release and Liability Waiver
Must be completely filled out for each Scout registering with our BPSA Scout Group.
Email address *
Scout's Name *
Your answer
Date of Birth *
MM
/
DD
/
YYYY
Parent/Guardian Name (First/Last) *
Your answer
Street Address *
Your answer
City, State, Zip *
Your answer
Emergency Contact #1 Name (First, Last) *
Your answer
Emergency Contact #1 Phone *
Your answer
Emergency Contact #2 Name (First, Last) *
Your answer
Emergency Contact #2 Phone *
Your answer
Physician Name *
Your answer
Physician Phone *
Your answer
Physician Address *
Your answer
Special Medical Information/Restricted Activities (if any):
Your answer
Allergies
Your answer
Immunizations Up-to-date? *
Date of Last Tetanus Shot (if known)
MM
/
DD
/
YYYY
Is s/he taking any medications? *
If you answered "Yes" above, please specify medications:
Your answer
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