Scout ______________________________________Medical Form  yes   no

Scout Cell phone_________________________________

Adult #1_____________________________________ Medical Form  yes  no

Address________________________________________________________

Member#_______________________________________

Home phone________________________Cell________________________

Work phone(for emergencies only)_________________________________

e-mail_________________________________________________________

Age_______Youth Protection________ Weather________

Balloo________ Safe Swim_______ Safety Afloat________

CPR Agency______________________________ First Aid Agency__________________________________________

Kind, year & make of vehicle_________________________________

# seat belts______ Vaild DL –  Yes   No

Owner’s name_________________ Insurance each person__________ each accident____________Property damage____________