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

COMPLETE THIS FORM AT

REGISTRATION

TROOP LEADERS PLEASE EMAIL THIS FORM

Girl Permission Form

October 1, 20__ to September 30, 20__

THIS FORM WILL BE RETAINED BY THE TROOP/GROUP LEADER FOR ALL REGISTERED MEMBERS. A COPY MUST BE ON FILE WITH COUNCIL

Girl Name:

Troop:

County/Service Unit:

Street Address:

City:

State:

Zip Code:

Phone #:

Other Phone:

Grade (fall 2017)

Birth Date:

School:

Parent/Guardian Contact Name

Phone #:

Relationship to Child

Emergency Contact Name

Phone #:

Relationship to Child

Permission for Trips

My daughter/dependent has my permission to participate in field trips. She is in good physical condition and has not had any serious illness or operation since

her last health exam.

Permission for Media Use

I/We 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). We

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 a parent/guardian or emergency contact. If no contact can be made, I hereby give

authorization to Girl Scouts of Southern Alabama to seek treatment for my child and/or dependent minor by a licensed physician or dentist. I know of no

reason(s) why my daughter/dependent may not participate in prescribed activities except as noted on the Health History Form.

Permission for Water Activities

My daughter/dependent has my permission to participate in water activities and is a:

Non-swimmer

Beginning Swimmer

Intermediate Swimmer

Advanced S wimmer

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

My daughter/dependent requires 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, trips, and/or 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.

Printed name of Parent/Guardian

Signature of Parent or Guardian

Date

Girl Scouts of Southern Alabama

145 Coliseum Blvd, Montgomery, Alabama, 36109 / 3483 Springhill Avenue, Mobile, AL 36608

800-239-6636 /