TROOP 265

                           Parental Permission Form/Health Information/Release Form

 

Scout’s Name_____________________________                  Date ___________

Address__________________________________

City_______________        State________                     Zip Code______________

 

IN CASE OF EMERGENCY NOTIFY:

Name _______________________                     Relationship_______________

Address__________________________________________________________

Primary Phone # ________________      Secondary Phone # ________________

Other Instructions: _________________________________________________

Any conditions requiring regular medications? ________         

Name of Medication___________________ Special Instructions: _________________

_____________________________________________________________________

 

Parental Authorization:

 

Text Box: This health history is correct as far as I know and the person herein described has my permission to engage in all activities, except as noted by me and our physician. In the event I cannot be reached in an emergency, I hereby give permission to the physician, selected by an adult leader in charge, to hospitalize, secure proper anesthesia, or to order injection or surgery for my child. Having been informed of the organization of the Troop 265 outings, we, the parent(s)/guardian(s) of the above Scout/Scouter, do hereby give our approval of his participation in any and all activities of the outing. We do assume all risks and hazards incidental to the conduct of activities, transportation to and from the activities, and we do further release, absolve, indemnify and hold harmless the organizer, sponsor, leader of Boy Scout Troop 265, any and all of them. In case of injury to our child, we hereby waive all claims against the organizers, sponsors, and leaders of Boy Scout Troop 265, appointed by them.

 

 

 

 

 

 

 

 

 

Signature _____________________________ Date: _____________

 

Are you able to drive?  ‡ Yes  ‡ No

 

Outing location                                                                                    Date:

 

Paid by:  ‡ Cash  ‡ Check # ________   ‡ Account

 

--------$-----------------------------$------------------------------$----------------------------------$---------------

Retain this half for your reference

 

Troop 265 will be attending an outing to   _________ on ___________________

for _________ nights.  We will be leaving from the _______ _aprox. _________

 and returning _______________________________________________.

 

The cost for this event is $____________ per person. 

Monies and permission slip due by ____________ no exceptions!

 

The above signature is an authorization for your Scout/Scouter to attend this function.

 

 

Scoutmaster