BSA TROOP 628

PERMISSION SLIP AND EMERGENCY MEDICAL AUTHORIZATION

Pursuant to California Civil Code Section 25.8 and California Penal Code Section 12552
 

Name of Minor: ________________________________________________ Date of birth: _____/_____/_____  (MM/DD/YYYY)

Address: __________________________________________________________________________________________

Phone number: (_____)_________________   Alternate phone number: (_____)__________________

The undersigned do hereby authorize the Leaders of BSA Troop 628 as agents for the undersigned to consent to any x-ray examination, anesthetic, medical, dental, or surgical diagnosis for treatment and hospital care for the above minor which is deemed advisable by and to be rendered under the supervision of any physician licensed under the provision of the Medicine Practice Act or any dentist licensed under the Dental Practice Act.

This authorization will remain effective while the above minor has a current Boy Scouts of America registration, and is en-route to or from, or involved, or participating in any Scout program activity of the Orange County Council, Boy Scouts of America, unless revoked in writing by the undersigned.

Signature of Parent or Guardian: _________________________________________________ Date:___________________

 Insurance Carrier: ___________________________________________________________________________________

 Policy/Group numbers: __________________________________________________________________________________________

Allergies/Medical concerns: ____________________________________________________________________________

_________________________________________________________________________________________________

Revised: 10/2001