Permission Slip And/or Waiver Of Responsibility - Bsa Troop 945
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1
2Montgomery District, National Capital Area Council
BSA Troop 945 – Damascus, Maryland
Wildlife Achievement Chapter - Izaak Walton League, Sponsor
Garrett Smith, Scoutmaster
PERMISSION SLIP AND/OR WAIVER OF RESPONSIBILITY
Activity:__________________________________ Location: __________________________________________________
Departure date: ___________
Return Date: _______________
Activity Leader: __________________________
PLEASE FILL OUT FORM IN FULL
TROOP SUPPORT: Can parent help to transport to site?
No
Yes ................ from site?
No
Yes
Vehicle:_________________
Ins. Co.:________________ DL#____________
# Boys you can carry: _______.
year / type
Seat belt per boy a must!
Cell Phone: __________________________
Name of Adult Camper(s): ______________________________________
PARTICIPATION WAIVER for my son, 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, 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, Wildlife Achievement
Chapter of Izaak Walton Leagues of America 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.
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:
(____)__________/_______________ or (____)_______________/_______________. If we/ I can not be reached please
phone / location
phone / location
contact: (name)_________________________ at (phone)________________
(relationship to boy)__________________
Scout’s physician _________________ Phone:________________________
Scout’s Allergies:
_______________________________________________________________________________________
Scout’s Currently prescribed medication: _____________________________________________________________________
Instructions for dispensing this medication
:
_____________________________________________________________________________________
Do you want the unit leader to carry this medication?
no
yes
(Please have medication clearly marked and preferably in original container clearly marked with Scout’s name)
Tetanus Shot: Date of last tetanus shot or booster: _____________________________
Family Medical Insurance: Company: _________________________ Policy # __________________ Group # ________
To be completed by troop scribe (SB-Scout Bucks; C-Cash; CH-Check please note check#)
FEES PAID:
Adult food_________
Adult camp fee_________
Scout food_________
Scout Camp fee
_____________
Received by__________________________ Date: ____________________
Form Revision 8/2011
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