Informed Consent and Hold-Harmless Agreement

I understand that participation in the ____________________camping trip, offered through 

Corsicana Troop 258, involves a certain degree of risk.  I have carefully considered the 

risks involved and have given______________________________, my son, my consent to 

participate from ________________________________.

In case of an emergency, I understand every effort will be made to contact me.  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.

							____________________________________
							( Printed name of parent or guardian )

							____________________________________
							( Signature of parent or guardian )

							____________________________________
							( Date )

PLEASE PROVIDE THE EMERGENCY INFORMATION 
REQUESTED ON PAGE 2 OF THIS FORM.

EMERGENCY INFORMATION
(IN ADDITION TO PERSONAL HEALTH AND MEDICAL RECORD)

DURING THE ACTIVITY LISTED IN THE ATTACHED INFORMED CONSENT AND HOLD-HARMLESS AGREEMENT, I CAN BE CONTACTED AT THE FOLLOWING PHONES AND WILL ACCEPT LONG DISTANCE CALLS.

(_________) _________________________   OR    (_________) ________________________

THIS SCOUT IS HIGHLY ALLERGIC OR SENSITIVE TO:__________________________________________ 

__________________________________________________________________________________________ 

__________________________________________________________________________________________ 

WHAT, IF ANY, MEDICATION IS THIS SCOUT TAKING? 

__________________________________________________________________________________________  

__________________________________________________________________________________________

ANY SPECIAL INSTRUCTIONS FOR THIS MEDICATION? 

__________________________________________________________________________________________ 

__________________________________________________________________________________________

DO YOU WANT THE UNIT LEADER TO CARRY THE MEDICATION?

YES__________          NO__________

DATE OF THE LATEST OR LAST TETANUS SHOT / BOOSTER____________________________________  

MEDICAL INSURANCE INFORMATION:

COMPANY__________________________________POLICY NUMBER______________________________

CONTROL NUMBER IF GROUP POLICY_______________________________________________________ 

USE THIS AREA FOR ADDITIONAL INFORMATION AND FOR EXPLANATION OF ANY OTHER PROBLEMS THE ACTIVITY UNIT LEADER SHOULD BE AWARE OF:

__________________________________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________
(SIGNATURE OF PARENT OR GUARDIAN)                                                                     (DATE)