Consent Form - Approval By Parents Or Guardians printable pdf download

CONSENT FORM

APPROVAL BY PARENTS OR GUARDIANS

For Boy Scouts, Venturers, and Guests under 21 years of age, participating in a troop, or crew trip or activity

First name of BSA member and middle initial

Last name

Address

Birth date (month/day/year)

Additional address (need street address if you have a P.O. box)

City

State

Zip

(_______)____________________________

(_____)___________________________

Area code and telephone no. (parent's business no.)

Area code & telephone no. (home)

Phone # I can be reached at during activity (_______)________________________________

Activity/outing/trip, etc.

Date (s)

Father/Mother/Guardian Signature

Date

PARENTS OR GUARDIANS

(Please read all the statements before giving approval for participation in the activity listed above.) I hereby approve and

agree to all of the terms, conditions, and waiver of claims of this consent form and certify to its correctness. Further, I

agree that this BSA youth member or guest can meet the health and physical fitness requirements of the trip or activity.

MEDICAL RELEASE

It is understood that in the event of a serious illness

Insurance Company______________________

or injury, reasonable efforts to reach me will be

Policy No.______________________________

attempted. In the event of illness or injury occurring

Physician ______________________________

to my son or daughter while involved in this trip or

Physician Telephone No. (_____)____________

activity, I consent to X-ray examination, anesthesia,

Special Medication required? Yes ___ No _____

and/or medical or surgical diagnostic procedures or

Special medical condition?

(eg recovering injury, etc.)

treatment considered necessary in the best judgment

_______________________________________

of the attending physician and performed by or under

_______________________________________

the supervision of a member of the medical staff of

_______________________________________

the hospital furnishing medical services.

Early Release

In the event that the scout needs to return early, he will need parental permission prior to the outing, unless it is

an emergency. ‘I give permission for my son to leave the outing early. I understand that he may not credit for

the outing if he fails to participate in the main activities at the outing. Outing that needs early pick is

____________________________________. He will be picked up on ___________ (date) at __________

(time) by _____________________________ (name & relationship to scout). He needs to leave early for

__________________________________________________________________________ (state reason.)

Signed by: __________________________ Father or Mother or Guardian Signature Date: _________

TROOP 494

Revised 1/1/09

Consent Form - Approval By Parents Or Guardians

Related Articles

Related forms

Related Categories