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

EVENT: Trask Camping Trip - March 2004 DATES: from Friday Mar 19 to Sunday Mar 21, 2003 Location: Camp Trask, Monrovia CA

Closest Hospital: Monrovia Community 323 S Heliotrope Ave Monrovia   (626) 359-8341

MEET AT: St Hedwig Parking Lot ON: Fri. 2/14/03 AT: 5:30 PM       Cost Per Scout $20.00

RETURN TO: St. Hedwig Parking Lot  ON: Sun. 2/16/03 AT: 11:30 AM or earlier
SCOUTMASTER / ADULT LEADER: Mr. Rick Lovdahl
EMERGENCY CONTACT: Mrs. Anne Lovdahl Phone: 562-795-5000

________________________PLEASE RETAIN TOP FOR YOUR RECORDS_______________________

MY SON ___________________________________ SSN: ____________________________

FROM: Fri. 3/19/04 5:30 pm TO: Sun 3/21/04 11:30 am LOCATION: Camp Trask

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:_______________________