TROOP 671 PARENT / GUARDIAN PERMISSION SLIP
troop671.ocbsa.org on the Internet

EVENT: Day-Hike Trip,            May 2003
DATES: from  Saturday May 10, 2003 to Saturday May 10, 2003 COST: $0.00 no food incl.
                                                                                                                                                                                PAID BY: n/a
LOCATION: San Gabriel Mountains                           CLOSEST HOSPITAL:

                        No Telephone                                                                                                      

MEET AT: St. Isidore parking lot  ON: Sat. 5/10/03 AT: 7:30 AM
RETURN TO:     St. Isidore parking lot  ON:     Sat. 5/10/03 AT:   ABOUT 3:00 PM
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:         Sat. 5/10/03 7:30 am     TO:     Sat. 5/10/03 ABOUT 3:00 pm         LOCATION: San Gabriel Mtns.

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: _______________________________
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