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

Form Due – 7/30/2004

EVENT: Philmont Expedition #803-D – Philmont Scout Ranch: Cimarron, NM        Aug 2004
DATES: from  Sunday Aug 1, 2004 to Monday Aug 16, 2004

LOCATION: Philmont Scout Ranch                                   
47 Caballo Road, Cimarron, NM  87714                                                           
(505) 376-2281 – emergencies ONLY

MEET AT: Amtrak Station: Fullerton  ON: Sun 8/1/04 AT: 6:30 PM
RETURN TO: Amtrak Station: Fullerton  ON:     Mon. 8/16/04 AT :  6:44 AM
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:         Sun. 8/1/04 6:30 pm     TO:     Mon 8/16/04 6:44 am         LOCATION: Philmont Scout Ranch

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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