TROOP
671 PARENT / GUARDIAN PERMISSION SLIP
troop671.ocbsa.org on the
Internet
EVENT: Campout at Firestone BSA
CAmp Jan 2003
DATES:
from Friday Jan 17, 2002 to Sunday Jan
19, 2003 COST: $25.00 food incl.
PAID BY: 1/13/03
LOCATION: Firestone BSA Camp
19001
Tonner Canyon
Rd.
Brea,
CA 92921
MEET AT: Saint Isadore ON: Fri.
1/17/03 AT:
5:30:00 PM
RETURN TO: Saint Isadore ON:
Sun. 1/19/03 AT:
11:00 AM
SCOUTMASTER / ADULT LEADER:
Mr. Rick Lovdahl & Phil Zasadny
EMERGENCY
CONTACT:
Mrs. Anne Lovdahl Phone: 562-795-5000
_ PLEASE RETAIN TOP FOR YOUR RECORDS ____ .
MY SON _________________________________________ SSN: ______________________________
FROM:
Fri. 1/17/03 5:30 pm TO: Sun 1/19/03 11:00 am
LOCATION: Firestone BSA Camp - Brea
I am ABLE / UNABLE to drive TO / FROM the event. My vehicle can transport ______ scouts/ scouters including myself. I certify that I have the required (BSA/BAC) amount of auto insurance, my vehicle is in good operating order and that all passengers will have seat belts. I also confirm that I have read and will obey the (BSA/BAC) auto safety requirements.
VEHICLE MAKE:_____________________________________ car / wagon / truck / van TAG No. _____________
I am ABLE / UNABLE to participate for the ENTIRE EVENT / FOLLOWING DAYS: ____________________
In case of an emergency, I understand that
every effort will be made to contact me. In the event that I cannot be reached,
I hereby give my permission to the physician selected by the adult leader in
charge to secure the proper treatment which may include emergency treatment,
hospitalization, anesthesia, surgery or injections of mediation to my son.
SIGNATURE:
_______________________________________________________
Date:
/ /
EMERGENCY CONTACT ____________________________ Tel#
________________ Relationship ______________
MEDICAL / HOSPITALIZATION INSURANCE INFORMATION
List of Medicines and attached directions for
use:
List of Medicines my son is allergic to:
List of items my son is allergic to (bee stings, cats, dogs, hayfever, any foods, rashes)
Name of Insurance Company:
___________________________________________________________________
Policy Number: _______________________________________ Group No: _____________________________
Name of Insured: _________________________________________ SSN:
________________________________
Insured Employer Info: ___________________________________ Tel. No:
_______________________________
____________________________________________________________________________________________
____________________________________________________________________________________________