BSA Troop/Post 325 Emergency Contact & Medical Information Form
Use the 'Submit' button at the bottom to send this data to the troop leaders.
Please be complete, most fields are required.

Scout name: Birthdate:

Address: Phone:

City, State, Zip:

School: Grade:

Scout email: (if different than parent's or guardian's)

Parent/Guardian #1 Information (Primary):  
Name:
E-mail:
Address:
City, State, Zip
Home Phone:
Cell Phone:
Employer:
Work Phone:
Occupation:
   
Parent/Guardian #2 Information (Secondary):
Name:
E-mail:
Address:
City, State, Zip
Home Phone:
Cell Phone:
Employer:
Work Phone:
Occupation:

Emergency Alternative: List someone who may be contacted if your child is unable to remain with the Troop/Post because of illness or injury and you can not be reached. They must be reliable and willing to take your child.

Name: Phone:

If you may be driving for any of the troop activities or outings, please provide the following information:

Driver Name

Driver
License #
Vehicle Year, make, and model
# of seat belts
 Car License #
Liability /person
Liability /accident
Property Damage Limit
 
 
 

Volunteer Position - Each scout’s parent or guardian must sign up for a position – this position or positions must involve a minimum of 20 hours of assistance (10 hours for fundraising activities). If you are already volunteering, please confirm your role. If you have not volunteered for a position and are not sure what you would like to do or what the responsibilities include for a particular role please refer to the TROOP 325 Family Guide – 2005 .

Click here to see a list of open volunteer positions.

Name: Position/Activity: (input required)

In addition, please check all areas below that you are interested in helping with.

Coordinating outings:
Fundraising activities:
Buying food for outings:
Merit Badge Midway helpers:
Help at summer camp:
Merit Badge Midway Lunch Coordinator:
Court of Honor refreshments:
ASM Scouts Own (religious):
Service projects coordinator:
Merit Badge Counselor:

------------- Medical Information --------------------------------

Medical Information/Disability/Medical Alert, if any

Is your child prone to or have any problems with:

Hemophilia: YES NO
Blood Pressure: YES NO
Heart: YES NO
Lungs: YES NO
Diabetes: YES NO
Choking: YES NO
Hearing: YES NO
Vision: YES NO
Kidney: YES NO
Cancer: YES NO

Other disease: If yes, please explain:

Does your child have asthma? YES NO , If yes, do they use/carry an inhalant? YES NO

Does your child have seizures? YES NO , If yes, type:

Usual Duration Treatment/Medication:

Does your child have special needs? YES NO

(Ex. wheelchair, behaviorial/learning disability, hearing or vision loss, prosthesis, glasses/contacts, hearing aid)

If so, what special needs?

Is your child a known carrier of:

Hepatitis B: YES NO Herpes: YES NO Tuberculosis: YES NO

Other carrier:

Does your child have any known allergies to:

Drugs: YES NO Food: YES NO Insect Bites: YES NO

Other allergy: YES NO ; If yes to any allergy, please explain:

Describe reaction:

Describe Treatment Have Sting Kit? ; Know use of?

Medications: List all medicines that your child takes, include frequency, dosage and time. Do not include vitamins.


Date of last tetanus shot/booster:

Medical Provider:
Dr. Phone

Address: City, State, Zip:

Our Medical Insurance is with:

Policy Number: Insurance Phone number:

Scout's Social Security Number:

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General comments:

Please prove to me that you are a human- what is t-h-r-e-e p+l+u+s f-o-u-r?

Press Submit to send this data to Troop 325:

IMPORTANT:
After successful submittal, you will be shown a screen with your responses. You might want to print a copy for your own records.

Thank you.