Troop 134 - Douglas, Ma
Permission Slip

(Please print this form and turn in the completed form to your unit leader)

Activity:

Activity Dates:

Name Phone No
Address

 

Parent / Guardian Home Phone
Emergency Contact: Emergency Phone
Scouts Doctor Doctor's Phone
Is your child taking Medication ? If Yes, include details of times and dosages.

 

Allergies / Additional info:

 

Health Care Provider: Plan No:
Other Restrictions:

 

In case of medical emergency, I understand every effort will be made to contact me. In the event that I cannot be reached, I hereby give my permission to the event leader to secure proper treatment for, order hospitalization, and order injection, anesthesia, or surgery for my child as named above as necessary.
Parent / Guardian Signature: Date: