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:

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WHAT, IF ANY, MEDICATION IS THIS SCOUT TAKING?

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ANY SPECIAL INSTRUCTIONS FOR THIS MEDICATION?

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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:

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(SIGNATURE OF PARENT OR GUARDIAN) / (DATE)