Medicals

Personal Details

Membership Number

Name*

Prefix First Last

Email*

Phone*

Date Of Birth*

Address*

Street Address Address Line 2 City County / State / Region ZIP / Postal Code Country

Doctors Details

Doctors Name*

First Last

Surgery Address*

Street Address Address Line 2 City County / State / Region ZIP / Postal Code Country

Surgery Phone

Next Of Kin

Next Of Kin Name*

First Last

Relationship*

Next Of Kin Phone*

Medical Information

Medical Conditions*

Does the participant suffer from: Asthma, Bronchitis, Diabetes, Epilepsy, Fits/Fainting/Blackouts, Headaches, Heart Conditions or any other condition? If none please enter None.

Allergies*

Does the participant suffer from any allergy e.g. food, medication? If none please enter None.

Disabilities*

Does the participant have any disabilities or special needs?

Dietary*

Does the participant have any special dietary requirements e.g. vegetarian, gluten free etc.

Is the participant receiving medical treatment or taking medicines at the present time?*

If yes to the above please provide details, if No please put N/A*

Are there any occasions you would not wish the participant to receive medical treatment*

If yes to the above please provide details, if No please put N/A*

I consent to photos being taken of myself and used for publicity and marketing*

U18's

May the participant be offered paracetamol in the event of minor aches and pains?*

Has the participant had a Tetanus injection (last 10 yrs)*

Contact with any infectious disease in last 2 weeks*

Are there any other medications you will be providing for use on your young person (e.g. creams)*

Is there any other information (e.g. bedwetting, sleepwalking …) you would like use to know?

If none please enter No

Please note: Participants under the age of 18 will require their parent or gardian to physically sign this form prior to the event taking place.

This form will be only used for the purpose it is intended for. In accordance with Scouting POR.

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Personal Details

Doctors Details

Next Of Kin

Medical Information

U18's

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