Troop 59 Big Trip 2011

Sample - Medical Emergency Form # 1

Medical Emergency Form – Group #1

Name of Participant: _____________________________

Will be traveling with Boy Scout Troop 59 from Clifton Springs, NY as follows:

Dates	Mode	Destination	Details
7/14/11	Driving	Rochester Int. Airport
7/14/11	Flying	JFK International Airport	Delta Flight 2407*
	Flying	Salt Lake City	Delta Flight 1275*
	Driving	Malad Summit Campground Idaho
7/15/11	Driving	Warming Hut, Big Springs Campground ID
7/16/11 – 7/18/11	Driving	Yellowstone National Park	Bridge Bay Campground
7/19/11	Driving	Backcountry Camping or Rodeo	Rodeo – Cody Wyoming
7/20/11 – 7/21/11	Driving	Yellowstone National Park	Grant Village Campground
7/22/11 – 7/23/11	Driving	Grand Teton National Park	Colter Bay Campground
7/24/11	Driving	Antelope Island Campground, Utah
7/25/11	Driving	Salt Lake City Airport
7/25/11	Flying	JFK International Airport	Delta Flight 1002*
7/26/11	Flying	Rochester International Airport	Delta Flight 4367*

*Flight numbers may change.

In the event that the emergency contact can not be reached in an emergency situation, I herby give permission to the physician selected by one of the adult leaders listed below to authorize: hospitalization, secure proper anesthesia, order injection, surgery or any other emergency medical treatment.

Name of Participant: ________________________

Name of Emergency Contact(s): ________________________

Phone Number(s): ________________________

______________________________ _______________

Signature of Participant Date

______________________________ _______________

Signature of Parent or Guardian Date

______________________________ _______________

Signature of Parent or Guardian Date

Home Address: _____________________________________

_____________________________________

Home Phone: _____________________________________

Cell Phone: _____________________________________

Insurance Information:

Company: ________________________________

Policy Number: ________________________________

Supervising Leaders on the trip will be:

Jim Conners Mark Shultes Paul Welker John Mueller Wendy Amidon

Brian Young Ken Smith Tom Brickle Dave Pierce