Troop 111 Emergency Medical Treatment Form for Adults

Emergency Treatment Release Statement: I hereby authorize the Troop Leadership and/or any licensed physician, EMT or other qualified hospital personnel to render medical treatment, which, in their judgement, is necessary in the event of decapacitating illness or injury to myself. I understand that, in all such cases, my designees will be notified as quickly as possible.

Full Name, Printed: _______________________________________________

_______________________________________________
  (Signature)     (Date)

Date Of Birth:   _________________________________________________
Full Address:    _________________________________________________
     _________________________________________________
Home Phone Number:  _______________________________________________
Husband's/Wife's Work Number:  _______________________________________________
Additional Permanent Emergency Number:  _________________________________
Name of person to contact at this latter number:  _____________________________
Relationship to Family:   ________________________________________________

Please list any and all allergies, special medical conditions, special medications or health problems with which Troop 111 should be aware:
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________

Are there any medications that you know of that are contraindicated for medications you are currently taking on a regular basis? Please list any and all medications that you take on a regular basis. Please include amounts taken, number of daily doses and routine administration times:
_____________________________________________________________________________
_____________________________________________________________________________

Blood type (if known): _______________________
Do you wear contact lenses?: _____________
Name of Family Doctor: __________________________________________
Office Phone Number: _____________________
Emergency Phone Number: ____________________
Medical Insurance Policy Name and Number: _______________________
____________________________________________________________
Emergency (or Prior Approvals) Phone Number: ____________________
Name of Family Dentist: __________________________________________
Office Phone Number: _____________________
Emergency Phone Number: ____________________
Dental Insurance Policy Name and Number: _______________________
Emergency (or Prior Approvals) Phone Number:____________________

Optional:
Are you an Organ Donor? __________
Do you have a "Living Will" arrangement? __________
Please use the free space below, as needed, to detail any necessary additional directions or clarifications. Please note that this information is held in strict confidence.

Return to the Troop 111 Homepage.
4 January 1998