Permission Slip And/or Waiver Of Responsibility Form - Bsa Troop 806
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BSA
RROHATTOC
ISTRICT
EART OF
IRGINIA
OUNCIL OF THE
W
U
M
C
,
OODLAKE
NITED
ETHODIST
HURCH
SPONSOR
J
, S
EFF LEE
COUTMASTER
PERMISSION SLIP AND/OR WAIVER OF RESPONSIBILITY
Activity :______________________________________________________ Location: _____________________________________________
Departure Date:____________
Return Date:____________
Activity Leader: _____________________________
PLEASE FILL OUT FORM IN FULL
N
S
C
: ____________________________________________________________
AME OF
COUT
AMPER
Name(s) of Adult Camper(s): _______________________________________________________ Phones: Home #:_____________ Cell#:_____________
Name(s) of Additional Family members Camping: ____________________________________________________________________________________
TROOP SUPPORT: Can parent help to transport to site? Yes:
No:
From Site? Yes:
No:
Vehicle (year/make):_____________ Ins. Co.:______________ # Number of Seats In Vehicle: ____ (NOTE: A seat belt per rider is required!)
Liability Insurance Coverage: Each person $__________
Each accident: $__________ Property Damage: $__________
PARTICIPATION WAIVER
for my son/ward, namely: __________________________________ from the ____________________Patrol. In consideration of
the benefits to be derived, and since the Boy Scouts of America is an educational institution, membership in which is voluntary, and having full confidence
that every precaution will be taken to ensure the safety and well-being of my Scout son/ward, named above on the activity identified above, I agree to his
participation and waive all claims against the leaders of this trip, officers, agents, and representatives of the Boy Scouts of America, and the Sponsor,
Woodlake United Methodist Church and its associations.
Upon an emergency, illness, or accident during the activity identified above, I understand every effort will be made to contact me. In the event that I cannot
be reached in a timely manner and our own doctor is not readily available, the troop or unit leader of the activity identified above has my permission to
obtain without delay medical treatment as judgment of medical personnel dictates. Proper medical treatment may include hospitalization, anesthesia,
surgery, or injections of medication for my son/ward.
Signature of Parent or Guardian: _______________________________________ Date: ________________
Printed Signature of Parent or Guardian:_______________________________________________________
EMERGENCY INFORMATION:
(Required update for troop Health and Medical Records).
During the activity identified above, We/I can be contacted at the following phone/ locations:
Home #:_____________ Cell #:_____________ or Alt#1: _____________ Alt # 2: _____________. If we/I can not be reached,
Alt. Contact: (name)__________________________ /(____)________________
)______________________
(Relationship To Scout
Scout’s physician ____________________________________ Phone:________________________
Scout’s Allergies: _________________________________________________________________________________________
MEDICATION: IF ANY SCOUT NEEDS TO TAKE MEDICATION OF ANY KIND DURING THE CAMPOUT, THE MEDICATION MUST BE HAND-
DELIVERED BY THE PARENT TO THE MEDICINE STAFFER BEFORE LEAVING WUMC. ALL MEDICATION MUST BE IN A ZIPLOCK BAG, CLEARLY
!!
NO EXCEPTIONS
LABELED WITH ADMINISTERING INSTRUCTIONS—
Scout’s currently prescribed medication: _____________________________________________________________________
Medicine Staffer:_____________________________________
Date of last tetanus shot or booster:____________
Family Medical Insurance: Company: ______________________ Policy # _____________________ Group # _____________
To be completed by troop scribe:
FEES PAID:
Adult food:______ Adult Camp Fee:______ Scout Food:______
Scout Camp fee:______
Received By:__________________________
Date:____________
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