Immunization. The following immunizations are recommended by the BSA. Tetanus immunization is required and must have been received within the last 10 years. If you had the disease, check the disease column and list the date. If immunized, check yes and provide the year received. Yes No Had Disease Immunization Date(s) Tetanus Pertussis Diphtheria Measles/mumps/rubella Polio Chicken Pox Hepatitis A Hepatitis B Meningitis Influenza Other (i.e., HIB) Exemption to immunizations (form required) Please list any additional information about your medical history: DO NOT WRITE IN THIS BOX Review for camp or special activity. Reviewed by: Date: Further approval required: Yes No Reason: Approved by: Date:
Appears in 14 contracts
Samples: stlbsa.org, www.twinvalleybsa.org, www.jerseyshorescouts.org
