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ERIE SHORES COUNCIL BOY SCOUTS OF AMERICA
C.O.P.E. Health/Understanding Form
Participant Name:_________________________ Age: _____ Course Date: _________ Address:___________________________________________________________ Number and Street, city zip Home Phone: ( ) _________________________________________________
Emergency Medical Information for Participant Check all items that apply to health history, past or present, and give explanation for all checks. Allergies Asthma _____ Food __________ Convulsions/Seizures _____ Medicine _______ Diabetes_______ Insects _________ High Blood Pressure ___ Other __________ Kidney Problems ______ Back Problems _____ Head/Neck Problems ___ Sprains ____ Broken Bones _____ Surgery ____ Hernia ___ Serious Injury ___ Serious Illness ___ Ears_____ Eyes __, Glasses___ Contacts _____ Nervous Condition ___ Teeth ___, Dentures _____, Bridge______ Mental Retardation ___ Fainting ________ Hemophilia ______ Heart Condition _____ , Murmur _______ Rheumatic Fever ___ Acrophobia / fear of heights ________ Claustrophobia (fear of narrow or closed spaces) ________ Last Tetanus toxoid innoculation date:__________________________________ List any medications to be taken, and schedule for them, while at camp: ____________________________________________________________ List any physical or behavioral conditions that might prevent full participation in strenuous physical and mental activities:_____________________________________ ______________________________________________________________________
Health/Accident Insurance Carrier: _________________Policy Number: _____________
In case of an emergency, please contact: Name: ______________________________ Address:________________________________________________________________ Business address and phone: ________________________________________________ Home Phone: ________________________ Relationship: _______________________ If the person named above is not available, please contact: Name: _________________________ Phone: _____________ Relationship: _________ Name: _________________________ Phone: _____________ Relationship: _________ Preferred Physician:_____________________ Phone:____________________________ Preferred Dentist: _______________________ Phone:____________________________ Emergency Medical Authorization I understand that every effort will be made to contact my spouse or next of kin at the above number(s). In the event that they can not be reached, I hereby give my permission to the physician selected by the adult leader in charge to secure proper treatment, including hospitalization, anesthesia, surgery, injections, or medication for me. Date: ______ Signature:__________________________________________________ Statement of Understanding I am aware in signing this statement of understanding for participation in C.O.P.E. that certain activities are physically, mentally and emotionally demanding. Physical fitness will increase my ability to participate. I shall consult with the Instructor before participation in any activity in which I feel my ability to participate may be limited or if I have questions about an activity. Some of the possible dangers that I may encounter while on the C.O.P.E. course include, but are not limited to, poison ivy, falling on the trail, cuts, bumps, bruises, insect bites, sprains, and fractures. Trained Instructors will supervise all activities to minimize risks. C.O.P.E. activities are held outside in all types of weather. I shall dress accordingly (rain gear, gloves, warm clothing). I recognize the necessity of following all safety procedures and instructions during activities on the C.O.P.E. course. I acknowledge the risks associated with this activity. Date: ___________ Signature of parent/guardian or adult participant:____________ Date: ___________ Signature of youth: ____________________________