Troop 9871
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Health & safety

Adult Health and Medical Form

Required for every registered adult and volunteer, kept on file for 12 months. It's what another leader reaches for if you need care on a campout.

Takes about 10 minutes. Only troop leaders can see what you enter. Events over 72 hours or at high altitude also need the Trail Life High Adventure Medical Form (a doctor signs that one).

Participant

Emergency contacts

Two people to call if you can't speak for yourself. At least one needs a phone number.

Emergency contact 1
Emergency contact 2

Insurance

Insurance company #1

Please attach a photo of both sides of the insurance card in the upload box near the bottom.

Physician

Allergies

Every known allergy — medication, food, environment — with the usual reaction and how to manage it.

Health history

Tick anything you currently have or have ever been treated for, and add a note. Leave the rest unticked.

Immunizations

Recommended, not required. For each one: immunized (and roughly when), and whether you have had the disease (and when). Dates as mm/yy are fine.

Tetanus
Pertussis
Diphtheria
Measles
Mumps
Rubella
Polio
Chicken pox
Hepatitis A
Hepatitis B
Meningitis
Influenza
Other (i.e., HIB)

Medications

Everything currently used — inhalers and EpiPens too, even if only for emergencies. Bring enough for the whole event, in the original containers, not expired.

Insurance card & extra pages

Limitations & notes

Permission & signature

I understand that if any information I have provided is found to be inaccurate, it may limit and/or eliminate the opportunity for participation in any event or activity.

I give permission for full participation in Trail Life USA activities, except where specifically limited in writing herein. As far as I know, this health and medical form is correct and complete.

In case of an emergency, I understand every effort will be made to contact my emergency contacts. In the event that they cannot be reached, I give my permission to the licensed healthcare provider selected by the Trail Life USA adult leader(s) to secure proper treatment, including related transportation, hospitalization, anesthesia, surgery, or injections of medication, except as noted below. I agree to the release of records necessary for treatment.

Submitted forms are stored privately and are only visible to troop leaders. The form is valid for 12 months from today.