BOY
SCOUTS OF
FT GATLIN DISTRICT
TROOP 28
Scout’s Name:_____________________________
1. (I) (We), the undersigned, parent (s) of __________________________, a minor. Do hereby authorize the bearer of this letter to act for the undersigned in the event that emergency treatment and/or hospital care is deemed advisable by, and is to be rendered under the general or special supervision of any licensed physician and/or surgeon.
2. It is understood that this authorization is given in advance of any specific diagnosis or emergency treatment being rendered.
3. We also agree that the bearer of this letter has permission to transport my youngster to and from, any Troop activity.
4. [ ] If my son becomes ill while attending a Troop 28 activity. I give my permission for the Scoutmaster/Registar Troop Scouter to issue the following non-prescription medications:
_____Pepto Bismol _____Imodium (anti-diarrhea)
_____Tylenol (acetaminophen) _____Calamine lotion
_____Advil (ibuprofen) _____Bendryl lotion
_____Mylanta _____Bendryl capsules
_____Tums _____Sore throat lozenge
[ ] I prefer that you not administer any non-prescription medications without contacting me first.
5. This form will remain in effect for one calendar year and can be modified at anytime by submitting a new form to the Scoutmaster.
SIGNED:________________________PHONE:_______________________DATE:________________
(Parent/Guardian)
_______________________PHONE:_______________________
(Parent/Guardian)
Family Physician :_____________________________ Phone:______________________________
______________________________Policy:______________________________
State of
Before me personally appeared _________________________ and person described in and who executed the foregoing instrument, and acknowledged to and before me that (he), (she), (they) executed said instrument for the purpose therein expressed.
Witness my hand and official seal.
This _____day of _________. 20____.
________________________
Notary Public