TROOP 230 CONSENT TO TREAT FORM
To be filled out by parent, guardian, or adult
participant. Please print in ink.
IDENTIFICATION
Name
____________________________________________ Date of Birth ______________ Age ____
Sex___
Name of parent or guardian
______________________________________________ Telephone ______________
Homc address
_____________________________________________City _____________________
State_____
If person named above is not available in the event of
an emergency, notify:
Name Relationship
________________ Telephone _________________
Name Relationship
________________ Telephone _________________
Name of personal physician ____________________________________________________________________
Personal health/accident insurance carrier
_________________________________________________________
I give permission for full participation in BSA
programs.
In case of emergency, I understand every effort will
be made to contact me (if an adult, my spouse or next of kin). In the event I
cannot be reached, I hereby give my permission to the physician selected by the
adult leader in charge to secure proper treatment,
including hospitalization, anesthesia, surgery, or injections of medication for
my child (or for me if an adult).
Date ______________. Signature of parent/guardian or
adult ____________________________________________
STATE OF
COUNTY OF ________________________
This instrument was
acknowledged before me on the _________ day of ____________________________
19____
by _________________________________________.
____________________________________________
NOTARY PUBLIC, STATE OF