CORPS AURORA NO. 142
NAVY LEAGUE CADET STATEMENT OF MEDICAL FITNESSPLEASE PRINT IN INK
Surname:Parent/Guardian: / Phone: / Given Names:
Care Card No: / Alternate Phone: / Birth Date: (D/M/Y) / M
F
Family Doctor: / Phone: / Blood Type:
The following information is required to assist Navy League Officers in determining the capabilities of the above-mentioned Cadet to participate in certain aspects of the Training Program which includes marching on a hard surface, swimming and other strenuous activities. This information will also be valuable in alerting the Officers to any potential medical, physical or psychological problem which might require some attention when the Cadet is undergoing training.
Has the Cadet suffered from any of the following:(Check appropriate answer) / Yes / No / Yes / No
Nervous trouble/breakdown / Rheumatism/arthritis
Head injury/concussion/
headaches / Stomach/bowel/rectal problems
Dizzy/fainting spells / Hernia
Convulsions/fits / Low back pain
Nose/throat/eye/ear trouble-indicate / Kidney or bladder trouble
Lung disease/chronic cough / Diabetes
Skin conditions:
Medications- / Menstrual problems causing significant disability
Hives/hay fever/asthma/
allergies-indicate: / Foot trouble
Motion/travel sickness / Broken bones
Heart trouble/shortness of breath / Tropical diseases
Hearing loss/impairment / Stuttering
Colour blindness to: / Bed wetting
Corrective lenses:
Nearsighted:______Farsighted:______/ Learning disabilities, e.g. Dyslexia
BC(1)-1OCT 1999
CORPS AURORA NO. 142
List any medications currently on:
Describe any illnesses, injuries or disabilities not listed above:
List any operations:
If you have answered yes to any of the above questions, please give any additional information you feel is pertinent.
I have completed this questionnaire and to the best of my knowledge, it reflects the medical fitness of the above-named Cadet applicant.
CONSENT:
“I hereby give my consent for my son/daughter/ward to participate in Cadet activities. If he/she is injured during such activities and I or other relations cannot be reached, I hereby give my consent for him/her to undergo emergency medical or dental treatment. I acknowledge that as Navy League Officers may not legally administer medication to Cadets, my son/daughter/ward is responsible for self-administering any properly prescribed medication he/she may require while undergoing training.”
DATE (DAY/MONTH/YEAR)PLACE (CITY)
SIGNATURE (PARENT/GUARDIAN)
NOTE:All information is strictly confidential and will be used only in case of emergency.
BC(1)-2OCT 1999