Troop 134 - Douglas, Ma Permission Slip

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

Activity:

Activity Dates:

Name:

Address:

Town:

Phone:

Parent / Guardian:

Emergency Contact:

Emergency Phone:

Scout's Doctor:

Doctor's Phone Number:

Allergies / Additional Info:

Health Insurance Plan:

Plan Number:

In case of medical emergency, I understand every effort will be made to contact parent/guardian. In the event that I cannot be reached, I hereby give my permission to the position selected by the leaders for the agents of the Troop to hospitalize, secure proper treatment for, and order injection, anesthesia, or surgery for my child as named above.


Signature:

Date:

HOME