FOR YOUR CHILD TO ATTEND THIS SCHEDULED EVENT, PLEASE RETURN THIS PERMISSION SLIP AND HEALTH FORM WITH YOUR MONEY TO THE CAMPO

FOR YOUR CHILD TO ATTEND THIS SCHEDULED EVENT, PLEASE RETURN THIS PERMISSION SLIP AND HEALTH FORM WITH YOUR MONEY TO THE CAMPOUT LEADER.

BOY SCOUT TROOP 110 CLINTON VALLEY COUNCILFARMINGTON, MICHIGAN

Trip: ___________________________

Dates: __________________________

________________________________ has permission to go on the above trip.

In consideration to the benefits to be derived, we expressively waive all claims against the troop (including officers, committee members, and sponsor, the local or national council or representatives) in the event of any accident, injury, illness, loss or other damage that can occur in connection with, or incident to, this activity. We believe our son is in good physical condition, unless we have noted otherwise below. Permission is granted to secure emergency medical and surgical treatment and routine, nonsurgical care for our son, a minor child, while in camp with the accordance of the Michigan public act No 116, M.C.L.A. 1973, 722.124A(2).

Parent/Guardian

Name________________________________

Address______________________________

Phone________________________________

Cell phone or pager number_________________________________

Signature_______________________________

If we will be unavailable in an emergency please notify:

Name____________________________Relationship to scout______________________

Address________________________________________________________________

Phone number____________________________________________________________

I can drive: ______________To this outing; _____________#of seatbelts for scouts

______________Back from this outing

______________Both to and back from this outing

I will_______________or will not____________be staying with the scouts

I am unable to drive at this time__________

Please call upon me to drive to another event________________

Major crossroads near my home to help facilitate return car groupings:

_______________________________and__________________________________

Health note: State any concerns, allergies, medications, etc.

____________________________________________________________________

Health insurance Co: ______________________________________

Policy or group number: __________________________________