______________________________________Age _______ Sex ________ Birth date ________________

_{Last Name                              First Name                              MI}

______________________________________       ___________________________________________

_{Address                                                                                                                                 City                                                                       State                                  Zip}                    

______________________________________

_{Youth Leader}

Immunization Record:

_{Please indicate date of immunizations of the following}

Tetanus/Diphtheria:           Polio:                     Measles:                Rubella:                                Hepatitis B:

DPT/TD                                 OPV/IPV               

_________                           ________             ________             ________             ________

_________                           ________             ________             ________             ________

_________                           ________                                                                             ________

_________                           ________

_________

Health History:

_{Check if these apply to your child:}                                                                          Allergies

________Rheumatic Fever                                                                Aspirin ________

________Asthma                                                                                               Penicillin______

________Epilepsy                                                                              Other Drugs _________________________

________Diabetes                                                                              Foods ______________________________

________Behavior _{(please describe- e.g. nosebleeds, bedwetting, headaches, sleepwalking, etc.)}

______________________________________________________________________________________

Precautions to be observed: _______________________________________________________________

Operations or injuries: ___________________________________________________________________

Medications:

Drug                                                             Purpose                                                Dosage

__________                                            __________                                     __________

__________                                            __________                                     __________

__________                                            __________                                     __________

In the event my child should have minor complaints of uncomplicated/simple headache, stuffy nose, cough, or diarrhea, I give permission for the registered nurse to administer over the counter medications to help alleviate the symptoms.

Please initial one:

                  ________ Yes, I give permission for the nurse to administer over the counter medications.

                  ________ No, I do not give permission for the nurse to administer over the counter medications.

I hereby certify that the above health record is, as of this date, accurate and complete.

________________________________                                            __________________

_{Signature of Parent or Guardian                                                                                                                              Date Completed}