Medical History And Consent Form

__________________________________________

Boy's name, last name first

MEDICAL HISTORY AND CONSENT FORM

A minor child brought to a hospital in an emergency situation (unless the situation is life-or-death) cannot receive medical treatment without a parent or guardian's consent.

FOR THIS REASON, IT IS REQUIRED THAT, FOR EVERY REGISTERED MEMBER OF THE BOY SCOUTS OF AMERICA UNDER 18 YEARS OF AGE

ON A PATROL OR TROOP OUTING, A SIGNED COPY OF THIS FORM BE PRESENT AND AVAILABLE IN CASE OF AN EMERGENCY.

PERSONAL IDENTIFICATION AND EMERGENCY CONTACT

Boy's Name____________________________________Birthdate___________

AUTHORIZATION FOR MEDICAL TREATMENT

Address_________________________________________________________

I, the undersigned, parent of_________________________________,

a minor, do hereby authorize any supervising adult of Troop 113 or

City/State/Zip_____________________________________________________

such substitute as he/she may designate as agent(s) for the undersigned

to consent to any x-ray, examination, anesthetic, medical, dental or

Home phone______________________________________________________

surgical diagnosis or treatment, and hospital care for the above minor

which is deemed advisable by, and is to be rendered under the general

Mother's Name____________________________________________________

or special supervision of, any physician and surgeon licensed under the

Address (if different)________________________________________________

provisions of the Medicine Practice Act or dentist licensed under the

Dental Practice Act on the medical staff of any acute hospital, whether

Phone____________________________or______________________________

such diagnosis or treatment is rendered at the office of said physician or

dentist or at a hospital, Scout Camp or elsewhere.

Father's Name_____________________________________________________

It is understood that this authorization pursuant to the

provisions of Section 6910 of the Family Code of California is given in

Address (if different)________________________________________________

advance of any specific diagnosis, treatment, or hospital care which the

Phone____________________________or______________________________

aforementioned physician or dentist in the exercise of his best

judgement may deem advisable.

Additional Contact___________________________Phone_________________

I hereby authorize any hospital which shall provide treatment

to the above-mentioned minor to surrender physical custody of such

Doctor_______________________________Phone_______________________

minor to the abvove-named agent upon completion of treatment. This

authorization is given pursuant to Section 1283 of the Health and Safety

Insurance______________________________Number____________________

Code of California, and Section 6910 of the Family Code of California.

This authorization will remain effective while the above

EMERGENCY MEDICAL INFORMATION

minor is enroute to or from or involved or participating in any Boy

Has or is subject to: (Check and give explanation below)

Scout program or activity of the Western Los Angeles County Council,

____Allergy to a medicine, food, plant, animal, or insect toxin

Inc., Boy Scouts of America, unless revoked in writing by the

____Any condition that may require special care, medication, or diet

undersigned and delivered to the aforesaid agent.

____Asthma

____Convulsions

____Heart trouble

____Glasses/Contacts

____Diabetes

____Cancer/leukemia

Date ___/___/___ Signed:___________________________________

____Fainting spells

____Hemophilia

____Chest/lung problems

(Father, Mother, or Legal Guardian)

Details:__________________________________________________________

________________________________________________________________

TRIP CONSENT AND RELEASE FROM LIABILITY

Any current health problems? ___No ___Yes (explain below)

I, the undersigned, parent of ________________________________,

Now under medical care or taking medicines? ___No ___Yes

a minor and a registered member of the Boy Scouts of America, do

IMMUNIZATION DATES:

Diphtheria_______________

Measles________________

Pertussis_________________

hereby give consent and permission for the above-mentioned minor to

Mumps_______________

Tetanus Toxoid____________

be taken on Boy Scout outings with Troop 113, so long as there is

Rubella________________

Polio____________________

present a supervising adult of Troop 113 who is a legal adult on the

Hep B vaccine (3)_____________________

outings.

In consideration of the benefits to be derived from the

IS THERE THE DISEASE OR HISTORY OF:

NO

YES

aforesaid outings, I hereby voluntarily waive any claim against the

NO

YES

Intestinal Problems

___

___

National Council of the Boy Scouts of America, the local council,

Serious illness/injury ___

___

Kidneys or urine

___

___

Troop 113, its sponsoring institution, all Scout leaders of the Boy

Surgery

___

___

Bed-wetting

___

___

ADD/ADHD

___

___

Scouts of America, and the owner and driver of any vehicle used for

Hernia

___

___

Dyslexia

___

___

transportation of the above-mentioned minor to and from the above

Sleepwalking

___

___

Learning disorders

___

___

mentioned outings, for any and all causes which may arise in

Nervous Condition

___

___

Emotional problems ___

___

connection with any Scout outing or any phase or part thereof.

Altitude Sickness

___

___

High blood pressure ___

___

This authorization shall remain effective until the child turns

Cerebral Palsy

___

___

Balance Problems

___

___

Tonsils/Teeth/Braces ___

___

18 unless sooner revoked in writing delivered to the leaders of Troop

Shortness of Breath

___

___

Broken bones

___

___

113.

Headaches

___

___

Heat problems/sunburn__

___

Skin, glands

___

___

Back, limbs, joints

___

___

Ears, Eyes

___

___

Date ___/___/___ Signed:__________________________________

Other (explain)

___

Nose, Sinus

___

___

(Father, Mother, or Legal Guardian)

YEAR/DETAILS (for any yes answers):________________________________