MEDICAL INFORMATION FORM
Name of Scout’s medical insurance company:
Policy Number:
Name of Insured:
Name and cell phone number of emergency contact:
Please list any allergies and medical conditions, and note whether they may impair the Scout’s
ability to participate in these projects:
Please include any other information necessary for medical personnel in event of an emergency:
I grant permission for {troop leader}, emergency personnel, or agents of Winthrop University to
provide emergency medical treatment to {Scout’s name} in the event of injury or illness while
participating in Scout projects at Winthrop University:
___________________ _______________
Parent/Guardian signature Date
Please return to:
Scout Projects at Winthrop University
College of Arts and Sciences
107 Kinard Hall
Winthrop University
Rock Hill, SC 29733
click to sign
signature
click to edit
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