POTOMAC DISTRICT ROYAL RANGERS

EMERGENCY MEDICAL INFORMATION AND AUTHORIZATION FORM

Ranger’s Name______Date of Birth______

Address______Phone______

City/State/Zip______

Father’s Name______Email______

Place of Employ. ______Work Phone ______

Mother’s Name______Email______

Place of Employ.______Work Phone______

Family Doctor______Office Phone______

Insurance Co.______Phone______

Policy Number______

Medical Questionnaire

Answer ALL of the following questions. Explain any “yes” answers completely on the reverse side of this form, other than #11.

Yes / No / Yes / No
1. Is your son presently being treated for any injury or illness or taking any form of medication for any reason? / 12. Does your son have any chronic medical problems? (i.e. cardiac, respiratory, other problems?
2. Does your son have asthma? / 13. Is your son color blind?
3. Is your son allergic to any form of medication? / 14. Does your son require a special diet?
4. Does your son have hay fever? / 15. Does your son sleepwalk?
5. Does your son have any other allergies? / 16. Is your son hyperactive? (If so, is he on medication?)
6. Has your son ever have his tonsils removed? / 17. May we give Tylenol, Aspirin, of Ibuprofen for pain or fever?
7. Has your son ever had his appendix removed? / 18. Are there any other medical considerations not mentioned above?
8. Has your son ever had any other operations? / 19. What was the date of your son’s last tetanus shot?
9. Is there any family history of any disease? / 20. What was the date of your son’s last physical exam?
10. Has you son had any ‘childhood diseases’
(i.e. measles, mumps, chicken pox, etc.)
11. Can your son swim? Circle one
Beginner Intermediate Advance

AUTHORIZATIONS

My son has permission to participate in any sanctioned activity of the Royal Rangers Training Camp provided he is supervised by authorized Royal Ranger leaders. I understand that qualified personnel will be available at all times throughout the camp and that I will be contacted as soon as possible in the event of an emergency (accident, injury, or illness). I authorize the Ranger staff to give consent for treatment of my son by licensed medical personnel in the event of such an emergency.

I understand that this form is effective continuously from the time of signature but may be changed or revoked at any time by notifying the Ranger staff. I agree to notify the Ranger staff in the event of any health changes which would restrict my son’s participation in any of the normal activities of the group. I also understand that the Ranger staff has the responsibility and right to restrict any person from any activity which he feels is beyond the physical capabilities of that person.

______

Signature of Parent or Legal GuardianDate