Troop 703 Consent Form

Approval by Parents or Guardians

 

 

 

 

Scout Name: ___________________________________________

 

Address: ______________________________________________

 

City: ________________________ State: _____ Zip: _________

 

Home Phone: _________________ Parent Cell: ______________

 

Alternate Contact Name/Number:__________________________

 

_____________________________________________________

 

Email Address: _________________________________________

 

Medical Release—In the event of illness or injury occurring to my child while

involved in troop trips or activities, I consent to X-ray examination,

anesthesia, and/or medical or surgical diagnostic procedures or

treatment considered necessary in the best judgment of the attending

physician and performed by or under the supervision of a member of the

medical staff of the hospital furnishing the medical services. It is understood

that reasonable efforts will be made to contact the above parent or

guardian.

Insurance:_____________________ Policy:__________________

 

Physician:___________________ Phone:____________________

 

Allergies:_______________________________________(Provide details on back)

 

Medications:____________________________________(Provide details on back)

You may Provide the following at scout leader discretion:

__Tylenol(Acetaminohen) __ Benadryl __ Motrin, Aleve(Ibuprofen)

__ Tums/Rolaids ___ Minor first aid as required

Attach copy of insurance cards (both front and back)

For: All Troop campouts and activities

Dates From: __July 1, 2007 to June 30, 2008___

Parent/Guardian

I hereby approve and agree to waiver of any and all claims against the

BSA, Troop, leaders or the chartering organization and certify that all information

on this form is correct. Further more I agree that this BSA

youth member or guest does meet the health and physical fitness requirements

for troop trips and activities.

Parent/Guardian Signature : _______________________________

 

Date : _______________________________