Gemstone District Cub Scout Day Camp June 15 – 19, 2015 Youth Application/Health Form Cost $70.00 (an additional late fee of $10 if received after May 25) !!! NO APPLICATIONS ACCEPTED AFTER JUNE 8 !!! Read this form carefully! A boy will not be permitted to participate in the Day Camp unless this form is completely filled out and the parent or guardian gives written approval by signing below. Mail this form, along with a check made payable to Piedmont Council, BSA, to: Cindy Bell P.O. Box 94 Mount Mourne, NC 28123 Please print: Name___________________________________________________ DOB___________________ Current Grade______ Pack #_______Rank at time of camp__________ Address_________________________________________________ (Wolf, Bear or Webelos) City_____________________________ State______ Zip:_________ Phone (Home)____________________ (Work)______________________ (Cell)____________________ Email (please print) ___________________________________________________________________ Health History: Family physician_________________________________________ Phone_________________ Have or is subject to: (check if yes) ______Asthma ______Carries inhaler ______ Heart Trouble ______Sports Restriction ______Diabetes ______Convulsions ______Fainting Spells ______Allergic Reaction (please specify)____ __________________________________________________ ______Carries Epipen Other (Describe in detail)___________________________________________ ______Check here if none of the above applies. Has Cub Scout had a recent DPT injection?________ When? ____________________________ Family Health Insurance Info: (Company)_____________________________ (Policy#)______________________ Other Instructions:__________________________________________________________________ _______________________________________________________________________________ Person authorized to pick up child__________________________________________________ In case of emergency notify: Name_________________________________________________ Relationship_____________ Phone (Home)____________________ (Work)______________________ (Cell)_____________________ Parent Authorization: This Health History is correct so far as I know, and the person (Cub Scout) herein described has permission to engage in all prescribed activities, except as noted by me in Other Instructions above. In the event I cannot be reached in an emergency, I hereby give permission to the physician, selected by the adult leader in charge, to hospitalize, secure proper anesthesia, and/or to order injection for my son. Signature_________________________________________________________________________________________________ Parent or Guardian Date Home # Cell# If your schedule permits, and you would like to work, check here: Yes______ No_______ Included in your child’s registration fee is one (1) T-shirt. This year you will be able to order your son’s T-shirt size, PLEASE, make your one (1) selection carefully as this will be the size given to your child. Consider one size bigger for him to grow into. ____ Youth - Medium ____ Youth - Large ____ Adult - Small ____ Adult - Large ____ Adult – X Large ____ Adult – 2X Large ____ Adult - Medium You will not be able to pre-order additional shirts so PLEASE do not send any extra money; there will be extra T-shirts available at camp registration days on a first come first served basis. For T-shirt questions contact Melba Ritchie 704-878-0628 Your son needs to bring a BACKPACK/BOOKBAG each day to carry his water bottle and items collected at program sessions. He also needs to bring a bottle of water each day.