Trip Permission Slip
to Bungle in the Jungle
Destination Date
Troop 103, Boy Scouts
of
Sponsor:
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:
___________________________________________________________________
_
I agree to his participation and waive all claims against the leaders of this Troop, Officers, Agents, and Representatives of the Boy Scouts of America, and the Sponsor. In the event of an emergency, the Troop Unit Leaders of the activity 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.
______________________________________________________ ___________________
Signature
of parent or guardian Date
I can be contacted at the following phones and will accept long distance calls:
______________________________________________________________________________
If I am not available, please contact:
___________________________________________ __________________
Name and Relationship Phone
EMERGENCY INFORMATION:
This Scout is highly allergic or sensitive to: _____________________________________
What, if any, medication is this Scout Taking? ___________________________________
Any special instructions that might assist
the adult leaders? __________________________________________
____________________________________________________________
MEDICAL INSURANCE
INFORMATION:
Company: _____________________________
Policy Number: ________________________
Control No. of Group Policy: ______________
Other: _________________________________
Name of Insured: _____________________
Is parent attending campout? ______________________________________
Payment Amount: $______________ Activity Fee $____________ Food
Payment Method: ______ Scout Account ______ Cash ______ Check