Boy scout troop 201 – olmsted falls

Boy Scout Troop 201 – Olmsted Falls
Consent, Authorization and Release

I consent to my son, _____________________________ participating in the activities
of the Boy Scout Troop 201 from the date of this release through December 31,
2012, or until this consent is revoked in writing.
I authorize the Troop 201 adult leaders to seek, select and implement emergency
medical, dental, surgical and hospital treatment for my son, and further authorize
any licensed physician or dentist to treat him as the physician or dentist deems
necessary.
I release Troop 201 adult leaders from any liability arising from such selection and
implementation of emergency treatment, and promise to hold them harmless and
reimburse them for any liability arising there from. The adult leaders or Troop 201
shall advise me of my son’s illness or injury as soon as possible. In addition Troop
201 adult leaders may return my son from treatment to camp or home if I am not
available.
Hospitalization Coverage_________________________ Group __________________
Code_________________________ Contract/ID/Record No. ____________________
Blood Type (if known) _______________ Faith ______________________________
Allergies/Other__________________________________________________________
________________________________________________________________________
Date of last Tetanus vaccination (very important) _____________________________
Residence address__________________________ Home Phone __________________
__________________________ E-mail_______________________
Father or legal guardian _____________________ Work Phone _________________
Cell Phone___________________
Mother or legal guardian ____________________ Work Phone __________________
Cell Phone___________________
Other Emergency Contact__________________________ Phone _________________
Relation to Scout_________________________________________________________

__________________________________________________ ____________________
Signature of Father or Legal Guardian

__________________________________________________ ____________________
Signature of Mother or Legal Guardian Date

PLEASE SEE OTHER SIDE FOR OVER THE COUNTER MEDICINE
ADMINISTRATION
(Please print legibly)
Boy Scout Troop 201 – Olmsted Falls
Authorization to Administer “Over the counter medicine”
I _____________________________________________ (mother) and _______________________________________________ (father) hereby give permission to the adult leaders of Boy Scout Troop 201 permission to administer the following “over the counter”medications/ or materials to my son. Mother’s Initial Mother’s initial Father’s Initial
I specifically do not want the following medications or items administered to my son.
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
Please complete the reverse side of this form for prescription medications to be
administered. Sign and date both sides of the form. Whenever possible both parents
should sign the form.
_____________________________________ Mother’s Signature __________ Date
_____________________________________ Father’s Signature ___________ Date
PLEASE SEE OTHER SIDE FOR TREATMENT PERMISSION
(Please print legibly)

Source: http://www.troop201.org/Forms/2012_COMBINED_PERMISSION_TO_TREAT.pdf