Troop 746 Parents / Guardian Permission Slip

TROOP 746 PARENTS / GUARDIAN PERMISSION SLIP

EVENT: Henson Scout Reservation

DATES: From : Friday 22 January 2016 To : Sunday 24 January 2016

LOCATION: CLOSEST HOSPITAL: Henson Scout Reservation Nanticoke Memorial Hospital 5700 Nanticoke Rd 801 Road 535 Rhodesdale, MD 21659 Seaford, DE 19973 410-202-0053 (302) 629-6611 COST: $20.00 **Hospital may change due to availability

MEET AT: St. Joe’s Parking Lot ON: Fri 1/22/2016 AT: 6:00 PM We will leave promptly at 6:30 PM

RETURN TO: St. Joe's Parking Lot ON: Sun 1/24/2016 AT: 12:00 PM

SCOUTMASTER / ADULT LEADER: Mr. Chuck Chamberlin Home: 410.218.0311 ______Please retain the top portion for your records______EMERGENCY CONTACT: ______PHONE NO. ______Cell ______Alternate Contact ______Alternate’s Phone ______

MY SON ______SSN: ______

FROM: Fri 1/22/2016 6:00pm TO: Sun 1/24/2016 12:00 pm LOCATION: St. Joe's I am ABLE / UNABLE to drive TO / FROM the event. My vehicle can transport ______scouts / scouters including myself. I certify that I have the required (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.

VEHICLE MAKE:______car / wagon / truck / van TAG No. ______

I am ABLE / UNABLE to participate for the ENTIRE EVENT / FOLLOWING DAYS: ______

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.

SIGNATURE: ______Date: / /

MEDICAL / HOSPITALIZATION INSURANCE INFORMATION

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, hayfever, any foods, rashes): ______

Name of Insurance Company: ______

Policy Number: ______Group No: ______

Name of Insured: ______SSN: ______Insured Employer Info: ______Tel. No: ______