Troop 413 Medical Release Form and Permission Slip

As the parent or legal guardian of   
                                                                               (Scout Name)
 I, hereby, give my permission for him to participate in an outing with Troop 413.

Dates of Outing:  March 19-21, 2010

Location:  Uwharrie National Forest

Date of Departure:   Friday, 03/19/10

Cost of the Trip:  $15.00

Time of Departure: 4:00pm

Place of Departure: Christ Covenant Church

Time of Return: 2:00pm Sunday, 03/21/10

Place of Return: Christ Covenant Church

Leaders In Charge:

ASM: Doug Leonard             doug.leonard@ccbcc.com                     704-904-0184

Cmte:  Nick Combs              ncombs@carolina.rr.com                       704-541-4173

Medical Information:

 Please List Any Medications to Be Taken on this trip:

Pertinent Medical Information (allergies, limitations, etc.):

Further, I give permission to the leaders of Troop 413 to render First Aid, should the need arise.  In the event of an emergency, I also give permission to the physician, selected by the adult leader in charge, to hospitalize, secure proper anesthesia, order injection, or secure other medical treatment, as needed.  I further agree to hold the above named unit and its leaders blameless for any accidents that might occur during this outing except for clear acts of negligence or non-adherence to BSA policies and guidelines.

 In case of emergency, I can be reached by phone at: (##########)
  (Home) or    (Cell). 

If I cannot be reached, please contact   (name) at     (Phone)                                                         

By clicking this option I certify I am the legal parent/ guardian of the scout listed above and herby approve my son to attend the above outing.                            

Parent /Guardian Electronic Signature