Sample - Medical Emergency Form #2
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Troop 59 Big Trip 2011
Medical Emergency Form –
Group #2
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 |
Syracuse Int. Airport |
|
7/14/11 |
Flying |
JFK International Airport |
Delta Flight 3772* |
|
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: