TROOP 450 PARENT / GUARDIAN PERMISSION SLIP BRING REGISTRATION FORM & PAYMENT TO AMY BELSON NO LATER THAN MAY 19, 2011 EVENT:

2011 Olympics and Cooking Campout

DATES:

Friday, June 3 to Sunday, June 5

COST:

$25.00 Scout (Adults free)

LOCATION:

Catoctin Mountain Park Poplar Grove Youth Group Area 14707 Park Central Road Thurmont, MD (301) 663-9330 (emergency only)

MEET AT: RETURN TO:

St. John's Parking Lot St. John's Parking Lot

CLOSEST HOSPITAL:

ON: FRI. 6/3/11 ON: Sun 6/5/11

AT: AT:

Waynesboro Hospital 501 East Main Street Waynesboro, PA 17268 717-765-4000

5:00 PM we will leave promptly at 5:15PM 11:00 AM (in time for 12:00 Mass)*

INFORMATION: PLEASE PAY ATTENTION AT TROOP MEETINGS AND TO EMAIL FOR UPDATES TO DEPARTURE TIMES. DIRECTIONS WILL BE PROVIDED AT OUR DEPARTURE POINT. PARENTS: PLEASE BE AVAILABLE BY PHONE ONE HOUR BEFORE SCHEDULED ARRIVAL TIME. SCOUTMASTER / ADULT LEADER: EMERGENCY CONTACT:

Michael Burnett (410) 808-1970 Amy Belson (410) 729-7230 (home) (443) 994-6827 (cell)

PLEASE RETAIN TOP FOR YOUR RECORDS -----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------MY SON _________________________________________ in the _______________________________ Patrol FROM:

Fri 6/3/11/11 5:00 PM

TO:

Sun 6/5/11 11:00 AM

LOCATION:

Catoctin Mtn. Park

CHECK ONE:

❏ ❏ ❏ ❏

I will not drive. I will drive in the carpool to the event on Friday night, stay for the whole trip, and drive in the carpool home on Sunday. I will drive in the carpool (check one) ❏ FRIDAY ONLY ❏ SUNDAY ONLY I do not plan to drive, but please contact me if you need me to drive. Preferred day: _________________________

ALL DRIVERS MUST READ AND COMPLETE: My vehicle can transport _____ people including myself. I understand the Troop is counting on me to help with transportation on this trip. I certify that I have the required (MD State & BSA/BAC) amount of auto insurance, my vehicle is in good operating order and that all passengers will have seat belts. I also confirm that I have read and will obey the (BSA/BAC) auto safety requirements.

❏

Special arrangements (arriving Saturday, etc.) please write HERE:_______________________________________________

In case of an emergency, I understand that every effort will be made to contact me. In the event that I cannot be reached, I hereby give my permission to the physician selected by the adult leader in charge to secure the proper treatment which may include emergency treatment, hospitalization, anesthesia, surgery or injections of mediation to my son. I understand that participation in this event does involve a certain amount of risk. I have considered this risk and have given my son my consent to participate. SIGNATURE: _______________________________________________________

Date:

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MEDICAL / HOSPITALIZATION INSURANCE INFORMATION: PLEASE COMPLETE ALL BLANKS. List of Medicines and attached directions for use: List of Medicines my son is allergic to: List of items my son is allergic to (bee stings, cats, dogs, hay fever, any foods, rashes) Name of Insurance Company: _____________________________________________________________________________ Policy Number: ________________________________________________ Name of Insured: _______________________________________________ Insured Employer Info:

Group No: ______________________ Insured’s ID #: _________________________

______________________________________

Tel. No: _______________________

Parent Cell Phone: _____________________