BSA TROOP 22

PERMISSION SLIP TO ATTEND A SCOUTING FUNCTION

This permission slip must be completed prior to the start of the event and must be carried by the participant at all times during the event.

I, ______________________ , hereby give permission for my son, ___________________ , to
attend the following Scout function:

Event: __________________________________________

Date : ______________________________

Start Time:___________________ End Time: _____________________

I agree to release and hold harmless any Scout Leader or volunteer driver of my son. If I am driving to the event, I represent and warrant that I am fully insured under the trip guidelines of the Boy Scouts of America.

To help the volunteer leaders of BSA Troop 22, please answer the following:
(Circle all that apply) My son has or is subject to Asthma; Diabetes; Communicable diseases; Fainting spells; Heart trouble; Convulsions; Bleeding disorders; Allergies to medication, food, plants, animals or insects; Any condition that may require special care, medication or diet.

Explain: ______________________________________________________________________

My son has difficulty with Eyes, ears, nose or throat; Digestion; Bed-wetting; Lungs; Sleep disorders.

Explain: _____________________________________________________________

_____________________________________________________________________________

I certify that my son is physically fit and can participate fully. I also authorize the leaders of BSA Troop 22 to obtain emergency medical attention for my son in the event that the leaders determine it to be required. If I cannot be readily contacted or circumstances do not permit my being contacted, I hereby authorize an attending physician to treat my son. My medical information and contact numbers are:

Medical Insurance Provider: _____________________________________

Plan Number:________________________________

Plan or Doctor Emergency Contact: _______________________________

My Home Phone:___________________________ Mobile Phone: _______________________

Other Emergency Contact Name: ________________________ Phone: ___________________

I understand that my son is responsible for his personal gear and clothing appropriate for the weather and activities and that he shall bnng appropriate spending money for snacks or other purchases. In an emergency I understand that I may be contacted to bring my son home.

Signature: _________________________ (Parent or Guardian). Date: _________________