Fillable Adult Permission Form - Girl Scouts Of Southern Alabama printable pdf download

COMPLETE THIS FORM AT REGISTRATION

Adult Permission Form

October 1, 201___ to September 30, 201 __

THIS FORM WILL BE RETAINED IN TROOP FILES FOR ALL REGISTERED MEMBERS. A COPY MUST BE ON FILE WITH COUNCIL.

Adult Volunteer Name:

Troop:

County/Service Unit:

Street Address:

City:

State:

Zip Code:

Phone #:

Home/Work Phone:

Birth Date:

Emergency Contact Name

Phone #:

Relationship to Adult”

DL # (optional)

DL State & Exp Date Automobile Insurance Company/Policy #

Driver Acceptance

I understand that when driving for Girl Scouts of Southern Alabama as a troop helper I am required to have a valid driver’s license and current liability

insurance. My driving record is free of at fault accidents and moving violations. I also understand that I will provide proof of a valid driver’s license and

current insurance upon request.

Permission for Media Use

I understand that when participating in Girl Scout activities the registrant may be photographed for print, video, or electronic imaging to be used in

promotional materials, news releases and other published formats for either Girl Scouts of Southern Alabama (GSSA) or Girl Scouts of the USA

(GSUSA). I acknowledge that the images will be the sole property of either GSSA or GSUSA.

Permission for Emergency Medical Treatment

In the event of an emergency, every effort will be made to contact an emergency contact. If no contact can be made, I hereby give authorization to Girl

Scouts of Southern Alabama to seek treatment for myself by a licensed physician or dentist. I know of no reason(s) why I may not participate in

prescribed activities except as noted on the Health History Form.

If permission for emergency medical treatment is not given, please prepare a signed statement providing the reason, a release

of liability, and alternate instructions and attach to this form.

HOLD HARMLESS

, on behalf of myself and my minor child (or children) or ward (if applicable), in consideration of the use of

real and personal property (“Property”) owned, leased, or otherwise controlled directly or indirectly by Girl Scouts of Southern Alabama, Inc.

(hereinafter referred to as the “Girl Scouts”) and/or the involvement and participation with any and all Girl Scout activities by myself and/or my

minor child or ward, hereby promise, covenant and agree to and with the Girl Scouts, its successors and assigns, that neither I, nor anyone

claiming through me, will hereafter bring, commence, prosecute or maintain, or cause or permit to be brought, commenced, prosecuted or

maintained, any suit or action, either at law or in equity, in any court in the United States or in any state thereof, or elsewhere, against the Girl

Scouts, or its successors and assigns, for, on account of, arising out of, or in any way related to or connected with any damages or injuries and/or

the results of any injuries arising from or related to the use of the Girl Scouts’ Property and/or the involvement with, or participation in, any and all

Girl Scouts’ camp or activity.

I further covenant that neither I nor anyone claiming through me will enforce, prosecute or recover upon, or attempt to enforce, prosecute or

recover upon, any claim or right of action whatsoever which I or my child or ward, or anyone claiming through me, may now have or may hereafter

assert in connection with the use of the Girl Scouts’ Property and/or the involvement with, or participation in, any and all Girl Scouts’ camp or

activity.

I further covenant that I will defend, indemnify, protect and hold harmless the Girl Scouts, and its successors and assigns, from any and all

claims, demands and damages arising from or related to my or my child’s or ward’s use of the Girl Scouts’ Property and/or the involvement with,

or participation in any and all Girl Scouts’ camp or activity, and I further covenant that I will pay and indemnify and hold harmless the Girl Scouts

against all loss, costs, expenses, and attorney’s fees incurred or expended in the prosecution or defense of any suit, action, claim or proceeding

relating to or arising from or related to my or my child’s or ward’s use of the Girl Scouts’ Property and/or the involvement with, or participation in,

any and all Girl Scouts’ camp or activity.

Special Accommodations

I require the following special accommodations:

Parent Agreement

I have read and understand this Annual Parent Permission form. This form may be used for online membership registration. I may

change or revoke permission for media and emergency medical treatment at any time by submitting my request, in writing, to the

troop/group leader.

The Hold Harmless Agreement may not be revoked.

Adult Volunteer Printed Name

Adult Volunteer Signature

Date

Girl Scouts of Southern Alabama