Boy Scouts of the Philippines

SULTAN KUDARAT COUNCIL

Lutayan District II

BOY’S APPLICATION FORM

EVENT: ____________________________ DATE: ______________________

PERSONAL DATA:
Name: ________________________________ Date of Birth: -
______________
Place of Birth: ________________________________ Age: ___________
Home Address: ________________________________ Tel. /Cel. No.
______________
School/District: LUTAYAN DISTRICT II Age Level: ___________
Date of Last Registration: _______________________________ No. of Years in Scouting: _____
Religious Affiliation: ________________________________
Person to notify in case of emergency:
Name: ________________________ Relationship: ___________________
Address: ________________________________ Tel/Cel No.:
______________________

_________________________________
Signature of Applicant

PARENT/ CONSENT FORM

TO WHOM IT MAY CONCERN:

This is to inform that I consent to the attendance of my daughter_

_____________________________at the ________________________________to be held at NEW
CARMEN, TACURONG CITY, SULTAN KUDARAT on ________________________________.

I have considered the benefits that my daughter will derive from her participation
safety in camp. I shall not held the Camp staff and the Boy Scouts of the Philippines
responsible for any untoward accident that may happened beyond their control. Her
physical fitness is assured in Medical Certification.

Thank you and with our best regards.

Very truly yours,

________________________________
Signature Over Printed Name of
Parent/Guardian

CERTIFICATION

We hereby certify that the application has met all the requirements of Participants
in this event.

________________________________
Troop Leader
________________________________ AKMAD M. MANTOG
School Head/HT/TIC District Commissioner
 Boy Scouts of the Philippines
SULTAN KUDARAT COUNCIL
Lutayan District II

HEALTH EXAMINATION FORM

Name: ____________________________________________________Birth Date: __________Age: ___

YRS. OLD
Surname First Middle
Address: ____________________________________________________ Tel/Cel No.
_____________________
Person to notify in case of emergency: _______________________________________________________

Name: ______________________ Relationship:

_____________________
Address: _________________________________ Tel/Cel No.:
_____________________

Past Personal History: ( To be filled-up by applicant before presentation to the physician)

Illness suffered: ___________________________________________________________________
Previous accident and/or injury: _______________________________________________________
Surgical operations, if any: ___________________________________________________________
Allergy (drugs, food or materials, etc.) __________________________________________________
Blood Type: ______________ Immunization (Give the kind and date):
__________________________
Any specific activities to be ENCOURAGED?______________________________________________
DISCOURAGED? ____________________________________________

Suggestion: In case of emergency , I hereby give permission to the Physician selected

coordinator to give proper treatment, order injections, hospitalize, give anesthesia or
perform surgery for our daughter.

________________________
Signature of
Parent/Guardian

PHYSICAL EXAMINATION- To be filled-up by licensed physician)

Code: V- satisfactory
X- Not Satisfactory (Please Explain)

Height: ________________________ Blood Pressure: ____________________

Weight: ________________________ Circulatory System: _________________
Eyes: __________________________ Blood Analysis: ____________________
Ears: __________________________ Urinalysis: ________________________
Nose: _________________________ Loco-Motor System: _________________
Throat: ________________________ Nervous System: ____________________
Allergy: (please specify if any) _________________________________________________
Menstrual History: _________________________________________________________
Genitalia: __________________________________________________________________
Recommendations and restrictions ( diet, medicine, swimming, diving, etc.)
______________________________________________________________________________
______________________________________________________________________________
 ________________________________
Examining Physician (District
Nurse)

Address: __________________________________ Tel. No./Cel No.: _____________________