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| WASHINGTON WING                                                       |
|                                                                       |
| MEDICAL INFORMATION                                                   |
|                                                                       |
| If form is not legible you may not be selected for the activity. This |
| information is for Official Use Only and will not be released to      |
| unauthorized persons. Answer all questions as accurately as possible  |
| so that special activity staff can make themselves aware of any       |
| pre-existing medical problems or conditions and be alert to help you. |
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| **NAME:** Last Name, First Name, Middle Initial **Date Joined CAP**   |
|                                                                       |
| **             ** Month: Year: **    **                               |
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| **MAILING ADDRESS**: (Number and Street) **UNIT CHARTER NUMBER**      |
|                                                                       |
|       PCR-WA-                                                         |
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| **CITY STATE ZIP CODE HOME PHONE**                                    |
|                                                                       |
|                                                                       |
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| **CAPID CAP GRADE DATE OF BIRTH AGE**                                 |
|                                                                       |
|       MM DD    YYYY                                                   |
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| **GENDER (circle) HEIGHT WEIGHT HAIR EYES**                           |
|                                                                       |
|                                                                       |
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| DO YOU CURRENTLY USE ANY MEDICATION? (Including eye drops & birth     |
| control pills) NO YES                                                 |
|                                                                       |
| (Give the date and reason in the remarks section.)                    |
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| HAVE YOU HAD OR BEEN INVOLVED IN AN ACCIDENT IN THE PAST 2 YEARS? NO  |
| YES                                                                   |
|                                                                       |
| (Explain the extent of your injuries and treatment required in the    |
| remarks section.)                                                     |
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| HAVE YOU HAD OR HAVE NOW ANY OF THE FOLLOWING? (If **yes** is         |
| answered on any items, please **explain** why in the remarks section  |
| with dates and physician(s) consulted (if any). Items not             |
| specifically noted below having the potential to interfere with       |
| performance during the activity should be documented in the remarks   |
| section.)                                                             |
|                                                                       |
| **No** **Yes Frequent or Severe Headaches** **No** **Yes Ear          |
| Infections** **No** **Yes Hay Fever**                                 |
|                                                                       |
| **No** **Yes Dizziness or Fainting Spells** **No** **Yes Rupture**    |
| **No** **Yes Attempted Suicide**                                      |
|                                                                       |
| **No** **Yes Unconsciousness for any reason** **No** **Yes Heart      |
| Trouble** **No** **Yes Asthma**                                       |
|                                                                       |
| **No** **Yes Eye Trouble, Excluding Glasses** **No** **Yes Epilepsy   |
| or Fits** **No** **Yes Motion Sickness**                              |
|                                                                       |
| **No** **Yes Kidney Stones or Blood in Urine** **No** **Yes Chronic   |
| or recurring injuries**                                               |
|                                                                       |
| **No** **Yes Sugar or Albumin in Urine** **No** **Yes GIRLS           |
| ONLY---Menstrual Cramps**                                             |
|                                                                       |
| **No** **Yes High or Low Blood Pressure** **No** **Yes Positive TB    |
| Skin Test**                                                           |
|                                                                       |
| **No** **Yes Other Illness or Accidents** **No** **Yes Chronic        |
| Diseases (Diabetes or Bronchitis)**                                   |
|                                                                       |
| **No** **Yes Stomach Trouble** **No** **Yes Any Drug or Narcotic      |
| Habit**                                                               |
|                                                                       |
| **No** **Yes Medication Allergies** **No** **Yes Admission to         |
| Hospital**                                                            |
|                                                                       |
| **No** **Yes Rejection for Life Insurance** **No** **Yes Military     |
| Rejection or Medical Discharge**                                      |
|                                                                       |
| **No** **Yes Food Allergies (Explain)** **No** **Yes Allergic         |
| Reaction to Bug Bites/Bee Stings (circle)**                           |
|                                                                       |
| **No** **Yes Seen a doctor in the last 5 years other than regular     |
| office visits or physicals (Explain)**                                |
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| **IMMUNIZATIONS**                                                     |
|                                                                       |
|                                                                       |
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| **FAMILY PHYSICIAN**                                                  |
|                                                                       |
| Name: [     ]{.underline}                                             |
|                                                                       |
| Address: [     ]{.underline} Phone Number: [           ]{.underline}  |
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**WWForm 24** January 2000 **PREVIOUS EDITIONS OBSOLETE** CONTINUE ON
THE BACK

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| **Remarks:**                                                          |
|                                                                       |
| [     ]{.underline}                                                   |
|                                                                       |
| [     ]{.underline}                                                   |
|                                                                       |
| [     ]{.underline}                                                   |
|                                                                       |
| [     ]{.underline}                                                   |
|                                                                       |
| [     ]{.underline}                                                   |
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| **Current Medications:**                                              |
|                                                                       |
| **[Name For Dosage]{.underline}**                                     |
|                                                                       |
| [                 ]{.underline}                                       |
|                                                                       |
| [                 ]{.underline}                                       |
|                                                                       |
| [                 ]{.underline}                                       |
|                                                                       |
| [                 ]{.underline}                                       |
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| **INSURANCE INFORMATION: [Do You Have Insurance?]{.underline}**       |
| **Yes** **No**                                                        |
|                                                                       |
| **[If yes, information below is REQUIRED:]{.underline}**              |
|                                                                       |
| **MEDICAL LIABILITY**                                                 |
|                                                                       |
| Company: [     ]{.underline} Company: [     ]{.underline}             |
|                                                                       |
| Policy Number: [     ]{.underline} Policy Number: [     ]{.underline} |
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| **EMERGENCY ADDRESS:** Parent, legal guardian or nearest relative to  |
| be notified in case of emergency                                      |
|                                                                       |
| Name: [     ]{.underline} Relationship:                               |
|                                                                       |
| Address: [     ]{.underline} City [     ]{.underline} State:          |
| [  ]{.underline}                                                      |
|                                                                       |
| Day Telephone [(   )      ]{.underline} Night Telephone: [(   )       |
|      ]{.underline}                                                    |
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| **RELEASE BY PARENTS OR GUARDIAN**                                    |
|                                                                       |
| **By my signature below I hereby give permission to treat my minor    |
| child in case of accident, disease or other illness and if my child   |
| is released from the activity before recovery from said injury,       |
| disease, or illness, further treatment will be provided by myself.**  |
|                                                                       |
| [     ]{.underline} [     ]{.underline}                               |
|                                                                       |
| DATE [Print Name]{.underline} of Father/Legal Guardian                |
| [SIGNATURE]{.underline} OF FATHER/LEGAL GUARDIAN                      |
|                                                                       |
| [     ]{.underline}                                                   |
|                                                                       |
| [Print Name]{.underline} of Mother/Legal Guardian                     |
| [SIGNATURE]{.underline} OF MOTHER/LEGAL GUARDIAN                      |
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**WWForm 24** January 2000 **PREVIOUS EDITIONS OBSOLETE** BACK PAGE