Scout Name

BOY SCOUT TROOP 23
2005-2006 WAIVER

STATE OF FLORIDA, COUNTY OF SARASOTA

I, the parent and/or legal guardian of hereby give my permission, should an accident or medical emergency arise during a Troop 23 function between the dates of September 2005 September 2006 for the adult leadership of Boy Scout Troop 23 to render immediate first aid, and, if necessary, to admit my son or sons to the emergency room of an accredited hospital or clinic for treatment or hospitalization if needed. To effectuate my consent as herein set forth, I hereby grant unto the adult leadership of Boy Scout Troop 23 my limited Power of Attorney, appointing them my true and lawful Attorney-in-fact with full authority to admit my son or sons for medical treatment or hospitalization as needed and to bind me financially to answer for same, as fully as could be done by me if I were present.

Parent / Guardian Signature
Home Phone
Work Phone
Other Phone
Witness
   
STATE OF FLORIDA, COUNTY OF SARASOTA
The foregoing instrument was acknowledged before me

on this the          day of                           , 20        , by                                               , Notary Public

My Commission expires:                            



MEDICAL CONDITION(S):

BLOOD TYPE: ALLERGIES:

MEDICATION(S):
PHYSICIAN NAME: PHONE #:
INSURANCE CARRIER:
POLICY #: GROUP #:

RELIGIOUS AFFILIATION (optional):

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