TROOP 671 PARENT / GUARDIAN PERMISSION
SLIP
troop671.ocbsa.org
on the Internet
EVENT: Canyon Campout at Featherly
Park Jan 2002
DATES: from
Friday Jan 25, 2002 to
Sunday Jan 27, 2002
COST: $20.00 food incl.
PAID BY:
1/21/02
LOCATION: Featherly Regional Park/Canyon RV CLOSEST
HOSPITAL: Kaiser Foundation Hospital
24001
Santa Ana Canyon Rd. 441 N LAKEVIEW AVE
Anaheim,
CA. 92802 Anaheim, CA 92807
(714)
771-6731 x216 (714)
279-4000
MEET AT: Saint Isadore ON: Fri. 1/25/02 AT: 5:30:00 PM
RETURN TO: Saint Isadore
ON: Sun. 1/27/02
AT: 11:00 AM
SCOUTMASTER / ADULT
LEADER: Mr. Rick
Lovdahl
EMERGENCY
CONTACT:
Mrs. Anne Lovdahl Phone: 562-795-5000
_ PLEASE RETAIN TOP FOR YOUR RECORDS ____ .
MY SON _________________________________________ SSN: ______________________________
FROM:
Fri. 1/25/02 5:30 pm TO: Sun 1/27/02 11:00 am
LOCATION:
Featherly Park - Anaheim
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:
/ / 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:
______________________________________
________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________