ACTIVITY PERMISSION SLIP – TROOP 22, BSA, East Haddam, CT

Activity Title:                                                   From:                        To:___________________________
Leader(s):__________________________________________________________________________
In consideration of the benefits to be derived, and in view of the fact that 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, namely:

Scout name(s):____________________________________________________________________

I agree to his participation in the activity named above and waive all claims against the leaders of the activity, agents, officers, and other representatives of Troop 22, the East Haddam Rotary Club (Troop 22’s chartered organization), and the Boy Scouts of America. In the event of an emergency, the activity leaders have my permission to obtain medical treatment at my expense for my Scout son from the nearest medical facility of a doctor of their own choosing , as restricted by information of the Emergency Data and Health Sheet on file with Troop 22.

During the activity listed above, I can be contacted at the following telephone numbers and I will accept reverse-charge-long-distance calls:  

Home phone or via:                                                           Beeper / other numbers:__________________________________

Additional contact instructions:

_____________________________________________________________________________________________

_____________________________________________________________________________________________

__________________________________________________________________________________

Special precautions/instructions: (allergies, current medication and instructions, problems the Activity Leader should be aware of)

____________________________________________________________________________________________

____________________________________________________________________________________________

My son is carried by health insurance:          Company Name:_____________________________________________

Health insurance policy number: ____________________________

Parent / Guardian Name: _______________________________________________________________

Parent / Guardian Signature:_____________________________________________________________

Date:                       

INFORMATION TEAR OFF FOR PARENT / GUARDIAN

Activity Title:                                                  Date: (from)                  (to) __________________________

ONLY IN CASE OF AN EMERGENCY, your son may be contacted through:

Name:                                                                          Phone: __________________________________

Name:                                                                          Phone: __________________________________