Fillable Parental Permission Single Activity Form printable pdf download

Parental Permission Single Activity Form

This form is mandatory for any activity outside of the normal meeting site/time. This

form is also mandatory whenever an activity involves a sensitive issue, including

activities occurring during troop meetings. Parents/guardians are required to

complete this form in order for their child to participate in the activity stated on the

form. Completed forms are to be returned to the individual stated on the form. This

form is to be retained by the troop leader for three years.

ACTIVITY INFORMATION (To Be Completed By the Troop/Group Leader)

Activity Type:

Day Trip

Overnight

High Adventure

Sensitive Issue

Description of Activity:

Activity Cost:

Transportation:

Activity Start and End Date(s):

Activity Location:

Departure Time and Location:

Return Time and Location:

Leader:

Adult-In-Charge:

Emergency Contact:

Phone 1:

Phone 2:

E-mail:

Additional Information:

Complete the Parent/Guardian Permission Statement below and return to:

by:

(Name)

(Due Date)

Note: All activities must be conducted in accordance with the Girl Scouts of the USA and the Girl Scouts Nation’s Capital’s policies,

standards, and guidelines regarding safety and adult supervision.

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PARENT/GUARDIAN PERMISSION STATEMENT (To Be Completed By the Parent/Guardian)

Name of Child:

Description of Activity:

CONTACT INFORMATION DURING THE ACTIVITY

Parent/Guardian:

Emergency Contact:

Phone 1:

Phone 2:

E-mail:

I understand that I am responsible for ensuring that my child is prepared to participate in this activity as determined by the leader. This may include, but is not limited

to, payment of fees and attending any preparation meetings. I also understand that I am responsible for ensuring that my child behaves appropriately during this

activity. I further understand that, if in the opinion of the leader or adult-in-charge, my child is not behaving appropriately, I may be asked to pick-up my child early from

the activity at my own expense, and that it is at the leader’s discretion whether or not to refund any fees that I’ve paid for this activity:

Yes

I understand that my child may not participate in this activity if she appears to be ill. I further understand that if my child appears to be ill when she arrives at the

activity or become ill during the activity, I will be asked to pick-up my child early from the activity at my own expense, and that it is at the leader’s discretion whether or

not to refund any fees that I’ve paid for this activity:

Yes

I understand that I must provide written permission for the first-aider to witness any medication that my child may need. I understand that this written permission must

include the name of the medication, the dosage, times and dates to be administered, and the reason for the medication. I understand that I must sign and date this

written permission and give it to the first-aider, along with the medication which must be in the original container:

Yes

When participating in Girl Scout activities, my child may be photographed for print, videotaped, or electronically imaged. Images may be used in promotional materials,

news releases, and other published formats for either the local Girl Scout Council or Girl Scouts of the USA. The images will be the sole property of either the local

Girl Scout Council or Girl Scouts of the USA:

Yes

For High Adventure Activities Only: I understand that during this activity, my child will be exposed to an above normal risk of injury. I understand that I am responsible

for communicating to the leader and adult-in-charge about any needs that my child may have in regards to this activity. I sustain to the best of my knowledge that my

child has the maturity, required skills, and physical ability to participate in this activity:

Yes

For Sensitive Issue Activities Only: I understand that during this activity, my child will be exposed to issues and discussions that are, or could be, considered to be of a

sensitive or controversial nature. I understand that I am responsible for communicating to the leader and adult-in-charge about any needs that my child may have in

regards to this activity. I am confident of her maturity and ability to participate:

Yes

My child is a registered Girl Scout, and I give her permission to participate in the activity described above:

Yes

Parent/Guardian Signature:

Date:

This form is available online at

Last Updated: February 2014