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

Form Due – 6/28/2004

EVENT: Summer Camp – Rancho Alegre – Santa Barbara        July 2004
DATES: from  Sunday July 18, 2003 to Saturday July 24, 2003

LOCATION: Rancho Alegre                                  CLOSEST HOSPITAL:  Santa Ynez Valley Hospital
4000 Modoc Rd., Santa Barbara, CA  93110                               700 Alamo Pintado Road, Solvang, CA 93463
(805) 686-5167 - emergencies                                              Phone 805-688-6431

MEET AT: St Hedwig School Parking Lot  ON: Sun 7/18/04 AT: 9:00 AM
RETURN TO: St Hedwig School Parking Lot  ON:     Sat. 7/24/04 AT ABOUT:  1:00 PM
SCOUTMASTER / ADULT LEADER:         Mr. Phil Zasadny / Mr. Greg Shoop
EMERGENCY CONTACT:                             Mrs. Denise Zasadny     Phone: 562-596-8288

                                                                                            _ PLEASE RETAIN TOP FOR YOUR RECORDS ____                                      .

MY SON _________________________________________ SSN: ______________________________

FROM:         Sun. 7/18/04 9:00 am     TO:     Sat 7/24/04 1:00 pm         LOCATION: Rancho Alegre

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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