Troop 55 Travel Permission Slip and Contact Information

Scout’s Formal Name _____________________________________________________ Scout’s Nickname ________________________________________________________ Parents/Guardian’s Names _________________________________________________ Home Address____________________________________________________________ Home Phone_____________________________________________________________ Contact Information: Parents/Guardians Cell Phone

_____________________________________________

Parents/Guardians Work Phone _____________________________________________ Alternate Contact Name____________________________________________________ Alternate Contact Phone(s)__________________________________________________ Scout’s Cell Phone________________________________________________________ Parents/Guardians E-mail___________________________________________________ Parents/Guardians E-mail___________________________________________________ Scout’s E-mail____________________________________________________________ Medical Information: Medical Insurance Company Name___________________________________________ Subscriber Name_______________________Relationship to Subscriber_____________ Subscriber #_________________________Group #______________________________ Scout’s Physician_________________________Phone____________________________ Medical Conditions________________________________________________________ Medications______________________________________________________________ Allergies (Medical or Environmental)__________________________________________ ________________________________________________________________________

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Troop 55 Travel Permission Slip and Contact Information Hold Harmless and Permission to Treat: I understand that participation in Scouting activities involves a certain degree of risk and can be physically, mentally, and emotionally demanding. I have carefully considered the risk involved and have given consent for myself or my child to participate in activities. I also understand that participation in these activity is entirely voluntary and requires participants to abide by applicable rules and standards of conduct. I release the Boy Scouts of America, the local council, the activity coordinators, and all employees, volunteers, related parties, or other organizations associated with the activity from any and all claims or liability arising out of this participation. In case of emergency involving my child, I understand every effort will be made to contact me. In the event I cannot be reached, I hereby give my permission to the medical provider selected by the adult leader in charge to secure proper treatment, including hospitalization, anesthesia, surgery, or injections of medication for my child. Medical providers are authorized to disclose to the adult in charge examination findings, test results, and treatment provided for purposes of medical evaluation of the participant, follow-up and communication with the participant’s parents or guardian, and/or determination of the participant’s ability to continue in the program activities. Participant’s signature_______________________________________________ Date ____________ Parent/guardian printed name __________________________________________________________ Parent/guardian signature ____________________________________________ Date ____________

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Troop 55 Travel Permission Slip and Contact Information Troop Tour Permit Information (We sometimes need additional drivers, please complete this section if you can help): Year/Make/Model of Vehicle_____________________________________________________ License Plate Number ___________________________ Owners Name__________________________________ Maximum # of Passengers__________ Drivers License #_________________________________________________________ Auto Insurance Company_________________________________________________________ Liability Each Person

$________________________ (BSA Minimum $50,000)

Liability Each Accident

$________________________(BSA Minimum $100,00)

Liability Property Damage

$ ________________________(BSA Minimum $50,000)

Training: Please fill in the completion dates for any of the following courses you may have taken: Youth Protection

________________(Expires 2 years from completion date)

Safe Swim

________________(Expires 2 years from completion date)

Safety Afloat

________________(Expires 2 Years From Completion Date)

Climb On Safely

_______________

Planning and Preparing for Hazardous Weather______________(Expires 2 Years From Completion Date) CPR___________________ Expiration Date_____________ (Expires 1-2 Years From Completion date depending on Red Cross or American Heart Certification)

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