BOY SCOUTS OF AMERICA
Medical Treatment Consent and Waiver of Liability
The undersigned, __________________________ (the “Participant”) (in the case of a minor, joined by his or her parent or legal guardian signing below), grants permission to the leaders of Troop ___ (the “Unit”) to seek and authorize any physician and any hospital deemed necessary to render any medical treatment as needed by the Participant. This consent is given in advance of any specific diagnosis or treatment being required, but is given to encourage said physician(s) to exercise his or her best judgment as to requirements of such diagnosis or treatments. The parent or guardian signing below understands that all possible efforts will be made to inform him or her in case of emergency.
In consideration of the Participant being permitted to participate in the Unit activities, the undersigned (in the case of a minor, joined by his or her parent or legal guardian signing below), for himself or herself, his or her heirs, executors, administrators and assigns, waives, releases and forever discharges the Unit, the Northeast Illinois Council, Boy Scouts of America, its leaders, committee members, officers and agents, and their heirs, executors, administrators and assigns, from any and all manner of action, suits, debts, accounts, damages, claims and demands whatsoever in law or in equity, which the Participant (in the case of a minor, joined by his or her parent or legal guardian signing below) now has or may acquire by reason of injury or death to the Participant, or loss of or damage to personal property, arising directly or indirectly out of or connected with or incidental to participation in the Unit activities. The word “activities” shall include campouts, field trips, hikes, meetings, or other events and any incidental activity in connection with the Scouting Program of the Unit.
This consent and waiver shall remain in effect until revoked in writing and delivered to the Unit leader.
Date:________________ Signature of Participant: _______________________
Signature of Parent or Legal Guardian: ________________________________
Name of Parent or Legal Guardian: ___________________________________
Home Address: __________________________________________________
Home Phone: ____________________ Work Phone: ____________________
Insurance Company: ______________________________________________
Policy Number: ___________________ Group Number: ___________________