Troop 681 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.