Medical History and Information
The following information is critical for the safe care of your Pathfinder during routine Pathfinder activities and emer-gencies. Please answer all questions as to “yes” or “no” & if “yes” explain with additional information.
Insurance/Physician/Emergency Contact Information/Parent or Guardian
Parent/Legal Guardian Atestation
Being the Parents/Guardians of the applicant I/we certify the above medical history and information is correct to the best of our knowledge and the applicant has permission to engage in all Pathfinder activities except those noted. In the event the I/we cannot be reached in an emergency, permission is given to the adult leader to whom the applicant is charged to hospitalize, secure proper anesthesia or physician, order injection, surgery, resuscitation, or any care deemed necessary by that leader or physician to insure safe return of said applicant to his/her Parents/Guardians. In addition, I have read and understand the Emergency Authorization statement and give my full consent to the terms found therein. Permission for photo copying of this health record is granted.