verdugo hills council, boy scouts of america (vhcbsa)

Verdugo Hills Council, Boy Scouts of America (VHCBSA)
Authorization to Treat a Minor & Parent’s Medicine Consent Form
(Pursuant to California Civil Code Section 25.8 and California Penal Code Section 12552)

Scout’s Name: _______________________________________________ Date of Birth: ______/______/________
Home Address: ____________________________________________________________________________________________________________

Telephone: _______________________________________ Cell or Pager: ________________________________
The undersigned does hereby authorize Troop/Pack Leader(s)/Advisor(s) of Verdugo Hills Council, Boy Scouts of America
(VHCBSA), or any such substitute as they may designate, as agent for the undersigned to consent to any x-ray examination,
anesthetic, medical, dental, and surgical diagnosis, treatment and hospital care for the above minor which is deemed advisable by
and to be rendered under general or special supervision of any physician or surgeon, licensed under the provision of Medical Practice
Act, or of any dentist licensed under the Dental Practice Act, whether such diagnosis or treatment is rendered at the office of said
physician or dentist, at a hospital, clinic, scout camp, or elsewhere. It is understood that this authorization is given in advance of any
specific diagnosis, treatment or hospital care being required, but is given to provide authority and power on the part of my (our)
aforesaid agent(s) to give specific consent to any and all such diagnosis, treatment or hospital care which the aforementioned
physician or dentist in the exercise of his/her best judgment may deem advisable. The Troop/Pack Leader(s)/Advisor(s)/Agent(s) or
their Designate will make all reasonable attempts to contact the scout’s parents or guardian prior to treatment.
This authorization will remain in effect while the above minor is enroute to and from, involved or participating in any Boy/Cub
Scout, High Adventure Team/Venture Crew(s), Verdugo Hills Council, BSA program(s)/activities.
This authorization will remain in effect until ____/___/____ (date the minor will be 18) unless it is revoked sooner in writing by the
undersigned and delivered to the aforesaid agent(s).

All medications that your Scout may need to take or use must be listed on this form. You should include both over-the counter
(OTC) medications and prescriptions. The following will be carried in the Troop/Pack First Aid Kit. You must indicate permission
for your Scout to have any of these, by initialing on the line after the medicine’s name and completing the OTC/Medication section.

Acetaminophen (e.g. Tylenol) (for pain/fever) _____
Mylanta (for upset stomach):
Tums (for upset stomach):
Dramamine (for motion sickness):
Sudafed (for nasal congestion):
Chlortrimeton (for itching/allergic reaction):______
Benadryl *for allergic reaction)
Sting Eze (for insect bites):
**Other medications which scout will bring to meetings/events. Please complete information requested.**
Over the Counter (OTC) Medications Prescription

Father (or guardian): __________________________________ ____________________________ _______________________ ___________________

Mother (or guardian): _________________________________ ____________________________ ________________________ __________________
Father HomePhone: (____) ______________________ Work: (____) ____________________ Cell/Pager: (_____) _________________ ___________________
Mother Home Phone (____) ______________________ Work: (____) ____________________ Cell/Pager: (_____) _________________ ___________________


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