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Appendix C Scouts Canada Physical Fitness Certificate NOTE This form is to be filled out by the parent/guardian at the beginning of each Scouting year and kept by the leader. It is the parent s/guardian s responsibility to update the leader of any changes in the medical condition of their child/ward throughout the Scouting year. This form should be filled out for adults as well* Surname Given Name Initial Date of Birth Age o Male o Female Address City Province Postal Code Home Phone Physicians Name Scout Group Name Provincial Medical Plan Number Insurance Coverage Held Emergency Medical Information Does the applicant have any allergies o Yes o No If yes please indicate below o Medicine o Insect Bites o Toxins o Plants o Animals o Food o Smoke o Other Details Has had please check x o Appendicitis o Scarlet Fever o Mumps o Chicken Pox o Measles o Kidney Disease o Rheumatic Fever o Heart Condition o Other If subject to any of the following check x and give details o Asthma o Contact Lenses o Headaches o Fainting Spells o Bleeding Disorders o HIV o Ear Problems o Diabetes o Hernia o Back Problems o Motion Sickness o Cramps o Convulsions o Sleepwalking o Nightmares o Bed Wetting o Pregnant Has participant menstruated o Yes o No If no has she had menstruation explained to her o Yes o No Does the participant require special care medication or diet Date of most recent physical examination Month and Year Date of last tetanus shot Month and Year Swimming abilities o Non Swimmer o Swimmer Highest Level Achieved Has it ever been necessary to restrict the applicant s activities for medical reasons o Yes o No Signed Parent/Guardian Date Updated Parent/Guardian Date Voluntary in some Provinces catalogue 91-113 March 2000. It is the parent s/guardian s responsibility to update the leader of any changes in the medical condition of their child/ward throughout the Scouting year. This form should be filled out for adults as well* Surname Given Name Initial Date of Birth Age o Male o Female Address City Province Postal Code Home Phone Physicians Name Scout Group Name Provincial Medical Plan Number Insurance Coverage Held Emergency Medical Information Does the applicant have any allergies o Yes o No If yes please indicate below o Medicine o Insect Bites o Toxins o Plants o Animals o Food o Smoke o Other Details Has had please check x o Appendicitis o Scarlet Fever o Mumps o Chicken Pox o Measles o Kidney Disease o Rheumatic Fever o Heart Condition o Other If subject to any of the following check x and give details o Asthma o Contact Lenses o Headaches o Fainting Spells o Bleeding Disorders o HIV o Ear Problems o Diabetes o Hernia o Back Problems o Motion Sickness o Cramps o Convulsions o Sleepwalking o Nightmares o Bed Wetting o Pregnant Has participant menstruated o Yes o No If no has she had menstruation explained to her o Yes o No Does the participant require special care medication or diet Date of most recent physical examination Month and Year Date of last tetanus shot Month and Year Swimming abilities o Non Swimmer o Swimmer Highest Level Achieved Has it ever been necessary to restrict the applicant s activities for medical reasons o Yes o No Signed Parent/Guardian Date Updated Parent/Guardian Date Voluntary in some Provinces catalogue 91-113 March 2000.

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