PERMISSION SLIP
Activity: Camp out
Date/Time Leaving: 5:30 p.m., Friday, . Leaving from: Overflow Lot, Willow Lakes Golf Course
Date/Time Returning: 10:00 a.m., Sunday, at the Overflow Lot, Willow Lakes Golf Course
Cost: $12 for food paid to the Patrol Leader.
Permission slips and money due,
Emergency Contact: Mike Livergood, (402) 215-9046
Please detach and retain this section and return the rest of this form and any cost NLT 6 Jan 11.
Activity: Camp Out
WAIVER OF RESPONSIBILITY
Troop 474 Boy Scouts of America
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(s)/ward(s), namely:
____________________________________________ on the activity named above, I agree to his participation and waive all claims against the leaders of this trip, officers, agents, and representatives of the Boy Scouts of America, and the sponsor.
In the event of an emergency, the troop unit leader of the activity named below has my permission to obtain medical treatment for this Scout at the nearest hospital or doctor, at my expense, if our own doctor is not readily available, and as restricted on the Emergency Data Sheet on file with Troop 474.
_______________________________________
(Signature of parent or guardian and date)
(Signature of parent or guardian and date)
EMERGENCY INFORMATION: (In addition to Personal Health and Medical Record.)
During the activity listed above, I can be contacted at:
Home Phone: __________________ Cell Phone: _________________ Other: _______________
Home Phone: __________________ Cell Phone: _________________ Other: _______________
This Scout is highly allergic or sensitive to ________________________________.
Date of the latest or last tetanus shot/booster _______________________
MEDICAL INSURANCE INFORMATION: Company _______________________ Policy No.
_____________________________ (Control No. if group policy) _________________
If your scout is taking medication, please fill out medicine form on reverse.
Parent/Adult Leader Information
I will attend this Troop activity. _____ Yes _____ No
I can transport scouts on Friday evening. _____ Yes _____ No
I can transport scout on Sunday morning. _____ Yes _____ No
If yes, how many passengers? _____________
Please ensure your scout brings a sack lunch or eats prior to leaving and wears his brown shirt.
MEDICATIONS FOR: _____________________________
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TIME(S) TO GIVE
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Special
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MEDICATION
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DOSAGE
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A.M.
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Breakfast
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Lunch
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Dinner
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Bedtime
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Instructions
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MEDICATION WAS GIVEN AS FOLLOWS:
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FRIDAY
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SATURDAY
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SUNDAY
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NOTES:
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My scout takes medicine for the following reason(s): ____________________________________
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If needed, I give the adults in charge permission to give my scout the following medicines as they
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feel necessary:
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Tylenol
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Ibuprofen
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Pepto bismo
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