Troop 681 Emergency Medical Treatment Form for Scouts 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 to my son ____________________________ which, in their judgement, is necessary in the event of illness or injury. I understand that, in all such cases, I will be notified as quickly as possible. _______________________________________________ (Signature of Parent or Guardian) (Date) 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 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: ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ 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 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:____________________ 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 judgement. Any medication marked "NO" will not be administered. Note that we do use generic products. Medication YES NO Advil, Tablets Analgesic Cream Rub Anti-fungal Powder 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