| NAME OF
SCOUT _________________________________________
In Case of an Emergency, I understand every effort will be made to contact me. In an event that I cannot be reached, I hereby give my permission to the physician selected by the adult leader in charge to secure proper treatment which may include dentistry, hospitalization, anesthesia, surgery, or injections of medication for the above-mentioned Scout at the nearest hospital or doctor/dentist, at my expense, if our doctor is not readily available, and as restricted on the Emergency Data Sheet on file with Mt. Diablo Silverado Council, or as indicated below. (Parent’s signature) ________________________________ Address: _______________________________________ Date: _______________________________________ IN CASE OF AN EMERGENCY, I can be reached at any time during this activity at the following phone number;
The trek leader is required to be advised and reserves the final authority to carry and administer this medication. Please use the space below for additional medical information the adult activity leader should be aware of.
I CAN DRIVE? -- yes or no (Please circle one)Type & Year of Vehicle ___________________________________ California Drivers License Number ____________________________ |