Parent Permission For Girl Scout Activity Form
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1Parent Permission for Girl Scout Activity
Troop/Group ____________
Activity ________________________________________________________________________________________
Date ____________Time ________________ Location __________________________________________________
Time and place of departure ________________________________________________________________________
Time and place of return __________________________________________________________________________
Mode of transportation ____________________________________________________________________________
Adults Accompanying the Group:
Name ___________________________________________________________Phone _________________________
Name ___________________________________________________________ Phone ________________________
Name ___________________________________________________________ Phone ________________________
Each Girl Will Need:
Expense _______________________________________________________________________________________
Equipment and clothing ___________________________________________________________________________
Please notify the leader if your daughter is exposed to any communicable diseases
within three weeks of an overnight activity.
In case of an emergency, the leader will notify:
Emergency Contact Person __________________________________________Phone _________________________
who will then notify the parent(s) or guardian.
Signature of Troop Leader __________________________________________ Phone _________________________
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(Return this portion to Troop Leader)
My daughter, ___________________________________has permission to participate in ______________________.
(activity)
She can participate with reasonable accommodations. Please describe.
_______________________________________________________________________________________________
During the activity, I can be reached at: _______________________________________________________________
Phone
I will not send my daughter if she is not feeling well and I will inform you that she will not be attending the
activity prior to the time of departure.
If I (we) cannot be reached in the event of an emergency, the following person is authorized to act in my (our)
behalf:
Name ______________________________________________________Relationship _________________________
Address ________________________________________________________ Phone __________________________
Your physician’s name ____________________________________________Phone __________________________
Address ________________________________________________________________________________________
In the event I cannot be reached in an emergency, I hereby give my permission to the physician, hospital or medical
service selected by the leaders to hospitalize, secure proper treatment for, and to order injection, anesthesia or surgery
for my child as named above. It is understood that a conscientious effort will be made to locate me or the emergency
contact listed before any action is taken.
Your signature ____________________________________________________________ Date __________________
(Parent or Guardian)
Address ________________________________________________________ Phone __________________________
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