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_____

Business 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 TEXAS

COUNTY OF ________________________

This instrument was acknowledged before me on the _________ day of ____________________________ 19____

by _________________________________________.

____________________________________________

NOTARY PUBLIC, STATE OF TEXAS