Troop 9871
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Health & safety

Youth Health and Medical Form

Required for every Trailman and kept on file for 12 months. It's what a leader reaches for if your son needs care on a campout, so the more complete it is, the better.

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

Parents first, then someone to call if neither can be reached. At least one contact needs a phone number.

Mother
Father
Other emergency contact (if parents can't be reached)

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 your son currently has or has 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 your son has 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.

No Trail Life youth member may self-medicate at an event except with emergency medication he understands how to use — that is what the second box records.

Who may take him to and from events

Adults authorized to pick up or drop off your son (beyond his parents).

Adults NOT authorized to take him anywhere (leave blank if none).

Insurance card & extra pages

Limitations & notes

Permission & signature

I understand that if any information I/we 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. I hereby give permission for Trail Life USA leadership to administer prescribed and over-the-counter medications.

In case of an emergency, I understand every effort will be made to contact me. In the event that I cannot be reached, I hereby 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 for my child, except as noted below. I agree to the release of records necessary for treatment.

More than one son? Submit this one, then choose Add another son — the family details carry over.

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