Troop/Crew 464 Medical Treatment Statement

(Info here will be used by Troop/Crew Medic when giving First Aid)


Scout Name____________________________                  Date________________


Scout Outing to _________________________                  Period Covered __________________


My son, _________________ can be treated with the following over-the-counter (OTC) medications:

      (First name)

(Please initial after each acceptable item. Circle the "X" if children's dose needed.)

Aleve ________                                                Pepto Bismol _____________


Aspirin ________                                              Mylanta ________   X


Tylenol (fever) ______    X                               Dramamine (original formula) __________
Advil (pain)______    X                                    
Dramamine (Non drowsy formula) _________ 
Motrin (pain)______       X                               
Imodium (for diarrhea) ______   X  

Sudafed _______     X                                       Benedryl (for minor allergic reactions) _____   X   


Claritin (antihistamine) _______    X                 Betadine swab (wound cleaner) _______


Tums _______                                                   Cortaid (Hydrocortisone anti itch cream) ______


All of the listed meds are OK ___________       Circle if copy of Insurance Card attached
Additionally, my son is allergic to the following (circle all that apply):


Bee Sting  Peanuts  Hard Work  Iodine  Sulfa Drugs  Penicillin  _____________    _____________

         (Fill in here)           (Fill in here)


No known allergies (circle here if applicable and Initial _____________)

Known history of any acute allergic reactions: ___________________________________________________________

I am providing the following Prescription Meds or OTC Meds for the following conditions:  _________________________

Insurance Carrier Name _____________________________  Insurance Phone # _________________


Insurance Policy/Record Number ___________________  Additional comments here: ____________




______________________________                     _______________________________

 (Signature of Parent/Guardian)                                      (Print Parent/Guardian name)