Troop 55 Parental Permission

EVENT:

DATE:

DEPART TIME:

RETURN TIME:

WHO SHOULD ATTEND:

COST:

EQUIPMENT:

UNIFORM:

PERMISSION SLIP TO BE RETURNED BY:

CONSENT FORM

APPROVAL BY PARENTS OR GUARDIANS

_______

First Name of BSA member/guest and middle initial                                           Last name

Address                                                                                   Birth date (month/day/year)

Additional address (need street address if you have a P.O. box)

City                                                                                          State                            Zip

(           )                                                                           (        )

Area code and telephone No. (parent's business)             Area code and telephone (home)

APPROVAL

(If two parents/guardians, both need to sign.)

FOR:                                                                                ON

(Name of activity, outing, trip, etc.)                                      (Date[s])

Father/Guardian Signature                                             Date

Mother/Guardian Signature                           ______    Date

PARENTS OR GUARDIANS

(Please read all the statements on the page before giving approval for participation in the activity listed above.) I hereby approve and agree  to all of the terms, conditions, and wavier of claims of this CONSENT FORM and certify to its correctness. Further, I agree that this BSA youth member or guest can meet the health and physical fitness requirements of the trip or activity.

It is understood that in the event of a serious illness or injury, reasonable efforts to reach me will be attempted.

Medical Release

In the event of illness or injury occurring to my son or daughter while involved in this trip or activity, I consent to X-ray examination, anesthesia, and/or  medical or surgical diagnostic procedures or treatment considered necessary in the best judgment of the attending physician and performed by or under the supervision of a member of the medical staff of the         hospital furnishing medical services.

Insurance company

Policy No.

Physician

Telephone No.(      )

Physician