Scout troop 85

SCOUT TROOP 85
PARENT PERMISSION & MEDICAL RELEASE FORM

I hereby give my permission for _______________________________________ to
(Scout’s name)
participate in the Columbus Clippers Dime-A-Dog Night, on August 22, 2011. I will not hold the
St. Paul parish, the Boy Scouts of America, or any of the leaders or accompanying adults of
Troop 85 responsible for any injury, loss or damage incurred during, or as a result of, the
Scouting activities of Troop 85.

In the event of illness or injury occurring to my son while involved in this activity, and following
reasonable attempts to contact me at __________________ or _________________, I hereby give
(phone)
(phone)
my consent for (1) the administration of any treatment deemed necessary by a licensed physician
or dentist and (2) the transfer of my son to any reasonably accessible hospital. This
authorization does not cover major surgery unless the medical opinions of two other physicians
or dentists, concurring in the necessity for such surgery, are obtained before surgery is
performed.
Following are facts concerning my son’s medical history including: allergies (insects,foods, iodine,
latex,etc.), drug interactions, all current medications and any physical impairments to which a
physician/aid provider should be alerted.
______________________________________________________________________________________
______________________________________________________________________________________
Unless specifically requested to the contrary on Scout’s current medical form and in the above
space, non-prescription medication(s) (such as: Aleve, Tylenol, Sudafed, Benadryl) will be
administered, per the instructions on the label, to a Scout that may become sick while on this
activity. Also, basic first aid will be administered.

________
__________________________________________
(signature of parent or guardian)

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PARENT’S INFORMATION SHEET

Activity/Event DIME – A- DOG
Location: Huntington Park, Columbus
Fee : --- $10
Dates: August 22, 2011
Drop Off Time: 5:30 PM
Pickup Time: 10:30 PM Will call 20 minutes out.
Drop-off/Pick-up Location: SCOUT SHED/Bus
Mr. Hart’s Cell – 614-565-0165



MEDICATION SCHEDULE FOR ______________________________________
Boy Scout Troop 85
I grant permission for Tom Hart at the HOLY ROSARY COMMUNITY KITCHEN on Nov 7, 2009 to
dispense the following prescription and/or non-prescription medications to the above named scout.
Typical non-prescription (such as Aleve, Tylenol, Dramaine, Benadryl) will be dispensed unless note
below. Medication is to be dispensed in accordance with the following schedule:
Morning: __________________________________________________________ Lunchtime: ________________________________________________________ Dinnertime: ________________________________________________________ Bedtime (other):_____________________________________________________ Medications to be on person (Epi-pen, insulin) _____________________________ Special Instructions, Drug interactions or Notes:_____________________________________ ____________________________________________________________________________ Signed: _____________________________ Date:_____________________ Print Name: ___________________________ ALL MEDICATIONS MUST BE IN ORIGINAL CONTAINERS WITH SCOUT/ADULT’S NAME, SCHEDULE AND DOSAGE INDICATED. ALL MEDICATIONS MUST BE IN A ZIPLOCKED BAG WITH SCOUT/ADULT’S NAME MARKED WITH “MAGIC MARKER”

Source: http://troop85bsa.com/PDF/dime%20a%20dog%20night.pdf