Emergency Medical Treatment

Troop 388 leaders, qualified medical technicians, and/or licensed health care providers may use the information below to treat your son (or ward) in cases of medical emergencies. By signing this form, you agree that this information is accurate and up-to-date, and you further agree to hold harmless the leadership of Troop 388 (including, but not limited to, Scoutmasters, Assistant Scoutmasters, Junior Assistant Scoutmasters, and Troop Committee members) and Greystone Baptist Church in the event of injury or illness resulting from this information's use.

In the fields that follow, 'n/a' or 'none' indicates that the no information is pertinent. When completed, please print two copies of this form and deliver to your Scoutmasters.

Personal information

Scout's Full Name:
Date Of Birth:
Home Phone Number:
Father's Work Number:
Mother's Work Number:
Additional Permanent Emergency Number:
Name of Person at Emergency Number:
Relationship to Family:

Personal medical statement

Please list any and all allergies, special medical conditions, special medications or health problems with which we should be aware:

Please list any and all medications that your son takes on a regular basis. Please include amounts taken, number of daily doses and routine administration times:

Are there any medications that you know of that are contraindicated for medications your son is currently taking on a regular basis?

Blood type (if known):
Does your son wear contact lenses?:

Medical contact information

Name of Family Doctor:
Office Phone Number:
Emergency Phone Number:
Medical Insurance Policy Name and #:
Emergency (or Prior Approvals) Phone #:
Name of Family Dentist:
Office Phone Number:
Emergency Phone Number:
Dental Insurance Policy Name and Number:
Emergency (or Prior Approvals) Phone #:

Administration instructions

The following medications may be carried in the Troop first aid kits. Please signify your approval to administer these medications to your son based on need and our judgment. Any medication marked "NO" will not be administered, even if our judgment deems it prudent.

Note that we do use generic products.

Medication Yes No
Advil, Tablets
Analgesic Cream Rub (Topical, Aspirin Free)
Anti-fungal Powder
Athlete's Foot, Chafing, Jock-Itch
Benadryl, Tablets
Benadryl, Topical Cream
Bonine (Motion Sickness), Tablets
Chloraseptic, Lozenges
Cortaid (Hydrocortisone), Topical Cream
First Aid Cream (Topical)
Immodium AD, Liquid (Anti-Diarrhea)
Immodium AD, Tablets
Lip Balm (Chapstick)
Luden's Cough Drops, Lozenges
Maalox, Tablets
Neosporin, Topical Cream
Sudafed Tablets

Printed Parent/Guardian Name:

Signed:
___________________________________________

Date Signed:
_________________

Date Completed:
Mon, 06 Feb 2012 03:10:57 -0500