Troop 75

Medical and Attendance Permission Slip

Scout Name:
Address:
City, State, Zip:
Function / Campout:
Dates:
I, the above named Scout, do hereby state that I will abide by the rules and regulations of Troop 75 and
the Boy Scouts of America during this function.

Scout Signature Date

As parent or legal guardian of the above named Scout, my son has permission to attend the function
stated above. To the best of my knowledge, my son is well and physically able to partake in all
activities of said function. My son takes no medications and has no allergies or medical conditions that
might prevent him from participating, other than those listed below on this form. If he must take
medication or has any medical conditions, I will notify the adult in charge prior to this function, and
will provide the necessary medication and directions for administration. My signature below authorizes
the adult in charge to administer these medications.

In the event of any emergency that demands immediate medical attention or other treatment decisions
be made, I authorize the adult in charge to use any discretion necessary on my behalf. I hereby give
permission to the physician(s) and other medical professional(s) selected by the adult in charge to
hospitalize, administer anesthesia, order injections, perform surgery, and to render medical treatment to
my son if the physician(s) and other medical professional(s) deem necessary. I understand that the adult
in charge will use the phone number provided below to contact me as soon as the situation allows.

Please Print Legibly In Ink

Parent / Guardian:
Emergency Phone Number:
Allergies:
Medications and instructions for administration:

Signature: Date