Consent to Medical Treatment of a Minor

I am the natural parent or legal guardiam of ____________________________, a minor, who is participating in certain programs sponsored by Troop 359 of Wilbraham, MA. In the event that I cannot be contacted and said minor shall, by reason of accident, illness or injury, require any character of medical treatment or surgery, including any and all diagnostic procedures or drugs related thereto. This instrument will authorize Scoutmaster Mike Palmioli, or his designee, to consent to the medical treatment of said minor and to do each and every act necessary to provide for said treatment.

_______________________________	_______________________________
Parent/Guardian Signature	Print Name of Parent/Guardian

_______________________________	_______________________________
Telephone Number	Number Attending

 

___ I will attend and drive

___ I can drive

Method of Payment:		___ Cash		___Check #		___ Scout Account
		$_______		$_______		$_______