or subject to (check if yes):
to any medication, food, plant, animal, or insect toxin.
condition that may require special care, medication, or diet.
here if none of the above applies:)
difficulty with (check if yes):
ears, nose, throat
condition now requiring regular medication? (If yes, please
there any restrictions of activity for medical reasons? (If yes,
the date of last inoculation
Parent Authorization ::
health history is correct so far as I know, and the person herein
described has permission to engage in all prescribed activities,
except as noted by me. In the event that 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,
or to order injection for my son.