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Permission Slip
As the parent or legal guardian of _________________________ , I hereby give my permission for this child to
participate in an outing with Troop 671.
Departure Time:
5:30 PM
Date:
02/13/04
St Hedwig Parking Lot
Return Time:
1:00 PM
Date:
02/15/04
St Hedwig Parking Lot
Activity:
Klondike Derby
Camp Emerson - Idyllwild
This form is due at the Troop Meeting on 1/12/04
The cost of this trip will be: $35 per scout
Please make checks payable to "BSA Troop 671"
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We will drive to Camp Emerson on Friday night and stay until we leave on Sunday morning.
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SCOUTMASTER / ADULT LEADER: Mr. Rick Lovdahl Cell Phone: (562) 889-8000
EMERGENCY CONTACT: Mrs. Anne Lovdahl Phone: (562) 795-5000
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 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 auto safety requirements.
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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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.
In case of emergency, I can be reached by phone at ____________________ or ____________________.
If I cannot be reached, please contact _________________________ at ____________________.
Signed: ______________________________ Date: _______________
(Parent or Guardian)