This consent form is for ____________________________________________,

who is a Boy Scout in Troop 284 (or is a guest of Troop 284) of West Seattle, WA. The consent herein described is given by

(Print adult name here)_______________________________________

who’s relationship with

the scout/guest is _____________________________________

The undersigned hereby authorizes any adult representing the Boy Scouts of America (BSA) and/or BSA Troop 284, (or any substitute they may designate as a sub-agent) as my agent to give consent to medical treatment for me or my dependant child.

(Print child’s name here)___________________________________ by any licensed physician, health-care provider, hospital, or nurse, being licensed to practice medicine in their state, according to their qualifications, when such treatment is deemed necessary by such health-care provider and I can’t be reached within a reasonable amount of time.

It is understood that this authorization is given in advance of any specific incident, diagnosis, treatment, or hospital care being required. It is given to provide the authority to consent thereto, as the said agent and attending health-care provider, may deem advisable in the exercise of their best judgement.

It is further understood that my child (or dependant child) will be taken to the closest hospital when possible unless medical attention is needed immediately and transportation would jeopardize the child’s well-being in the judgement of the attending medical professional; this unless further instructions are noted here.

_____________________________________________________________________

_____________________________________________________________________

My dependant child’s regular physician is____________________________________

Ph#__________________________________

Know allergies or important medical information (consider bee stings)

_____________________________________________________________________

_____________________________________________________________________

Insurance company

and policy #____________________________________________________________

PARENT/GUARDIAN

SIGNATURE / DATE__________________________________________/_____/____

PRINT NAME HOME PH# WORK PH#

_____________________________________________________________________

Others to contact in emergency

_____________________________________________________________________