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

EVENT: Horseshoe Meadow Backpacking Trip,            July 2004
DATES: from Friday July 16, 2004 to Sunday July 18, 2004  COST: $25. food incl.

LOCATION: Horseshoe Meadow & Pacific Crest Trail                    CLOSEST HOSPITAL: Southern Inyo Hospital
                        (near) Lone Pine                                                                                        501 E. Locust, Lone Pine
                        No Telephone                                                                                            Phone (760) 876-5501

MEET AT: St. Hedwig Parking Lot ON: Fri. 7/16/04 AT: 6:45 AM
RETURN TO:     St. Hedwig Parking Lot ON:     Sun. 7/18/04 AT:    about 8:00 PM
SCOUTMASTER / ADULT LEADER:         Mr. Rick Lovdahl & Mr. Kevin Black  
EMERGENCY CONTACT:                             Mrs. Anne Lovdahl     Phone: 562-795-5000

                                                                                            _ PLEASE RETAIN TOP FOR YOUR RECORDS ____                                      .

MY SON _________________________________________ SSN: ______________________________

FROM:         Fri. 7/16/04 6:45 am     TO:     Sun 7/18/04 8:00 pm         LOCATION: Eastern Sierra (Horseshoe Meadow)

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/OCC) 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/OCC) 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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