 |
Troop 134 - Douglas,
Ma |
|
Troop 134 - Douglas,
Ma |
(Please print this form and turn in the
completed form to your unit leader)
Activity:
Activity Dates:
| Name | Phone No |
| Address
|
|
| Parent / Guardian | Home Phone |
| Emergency Contact: | Emergency Phone |
| Scouts Doctor | Doctor's Phone |
| Is your child taking
Medication ? If Yes, include details of times and
dosages.
|
|
| Allergies / Additional info:
|
|
| Health Care Provider: | Plan No: |
| Other Restrictions:
|
|
| In case of medical emergency, I understand every effort will be made to contact me. In the event that I cannot be reached, I hereby give my permission to the event leader to secure proper treatment for, order hospitalization, and order injection, anesthesia, or surgery for my child as named above as necessary. | |
| Parent / Guardian Signature: | Date: |