TROOP
671 PARENT / GUARDIAN PERMISSION SLIP
troop671.ocbsa.org on the
Internet
EVENT: Scout-A-Rama,
May 2004
DATES:
from Saturday May 15, 2004 to Saturday
May 15, 2004 COST: $ 0.00
LOCATION: Hidden
Valley Park - Lion Country Safari
8770
Irvine Center
Drive
Irvine
MEET AT:
RETURN TO: Pick-up at Scout-a-
SCOUTMASTER / ADULT
LEADER: Mr. Rick
Lovdahl Cell Phone: 562-889-8000
EMERGENCY CONTACT:
Mrs. Anne Lovdahl Phone: 562-795-5000
_ PLEASE RETAIN TOP FOR YOUR RECORDS ____ .
MY SON _________________________________________ SSN: ______________________________
FROM:
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:
_______________________________
____________________________________________________________________________________________
____________________________________________________________________________________________