Troop 111 Emergency Medical Treatment Form for Scouts
Emergency Treatment Release Statement: I hereby authorize the Troop Leadership and/or any licensed physician, Emergency Medical Technician or other qualified hospital personnel to render medical treatment to my son ____________________________ which, in their judgment, is necessary in the event of illness or injury. I understand that, in all such cases, I will be notified as quickly as possible.
|
_______________________________________________ |
| Scout's Full Name: | __________________________________________________ |
| Date Of Birth: | __________________________________________________ |
| Full Address: | __________________________________________________ |
| __________________________________________________ | |
| Home Phone Number: | __________________________________________________ |
| Father's Work Number: | __________________________________________________ |
| Mother's Work Number: | __________________________________________________ |
| Additional Permanent Emergency Number: | __________________________________________________ |
| Name of Person at Emergency 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: |
| ______________________________________________________________________________________________________ |
| ______________________________________________________________________________________________________ |
| ______________________________________________________________________________________________________ |
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?: | __________________________________________________ |
| 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 #: | __________________________________________________ |
The following medications are 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. 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 | _____ | _____ |