Parent Permission Form - Girl Scouts Heart Of The Hudson
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Event, Trip, or Activity
Parent Permission Slip
Leader must carry this
Event, Trip, or Activity
Parent Permission Slip
Parent Permission Slip
Required for all girls participating Girl Scout sponsored
Required for all girls participating Girl Scout sponsored
Parent Name _____________________________ Phone: ____________
Parent Name _____________________________ Phone: ____________
activities other than regularly scheduled meetings.
Parent Name: ____________________ Phone: ____________
activities other than regularly scheduled meetings.
My daughter ________________________has permission to participate
My daughter ________________________has permission to participate
Troop # ______ is planning
My daughter ____________________has permission to participate
Troop # ______ is planning
_____________________________________
__________________________________
in ______________________________ held on ______________ .
in ______________________________ held on ______________ .
in ______________________________ held on ______________
(name of trip, event, or other activity)
(name of trip, event, or other)
(day/date)
(name of trip, event, or other activity)
(name of trip, event, or other)
(day/date)
(name of trip, event, or other activity)
(day/date)
on
_______ _____________
on _______ _____________
Name of person picking up child:______________________________________________
Name of person picking up child:______________________________________________
Name of person picking up child:_________________________________________
(day)
(date & year)
(day)
(date & year)
Location: ________________ Phone: __________
Location: _________________ Phone: ___________
In case of emergency,
In case of emergency,
In case of emergency,
notify: __________________________________ Phone: ___________
_________________
notify: __________________________________ Phone: ___________
notify: ______________________________ Phone: ___________
_____________
Mode of transportation:
_____________
Mode of transportation:
Relationship to girl: _____________________
Relationship to girl: _____________________
Relationship to girl: _____________________
Departure:
Return:
Departure:
Return:
In an emergency, when either myself or the person named above cannot be
In an emergency, when either myself or the person named above cannot be
In an emergency, when either myself or the person named above cannot
Time ___________
Time: _____________
Time ___________
Time: _____________
reached, I hereby authorize the adult in charge to take any action believed
reached, I hereby authorize the adult in charge to take any action believed
be reached, I hereby authorize the adult in charge to take any action
Place _____________ Place:_______________
necessary for the best interest of my daughter, including emergency room
necessary for the best interest of my daughter, including emergency room
Place _____________
Place:_______________
believed necessary for the best interest of my daughter, including
treatment.
treatment.
emergency room treatment.
Each girl will need:
Cost of event $________
Each girl will need:
Cost of event $________
Have there been any changes in your daughter’s health or insurance carrier
Have there been any changes in your daughter’s health or insurance carrier
Have there been any changes in your daughter’s health or insurance
Equipment and clothing
Equipment and clothing
since the Health History form was last filled out?
No
Yes
since the Health History form was last filled out?
No
Yes
carrier since the Health History form was last filled out? No Yes
_________________________________________
___________________________________________
If yes, list on back
If yes, list on back
If yes, list on back
___________________________________________
Leader’s
Will medications be administered during event? No Yes
Will medications be administered during event? No Yes
Will medications be administered during event? No Yes
Name:_______________________________
If yes, write type, dosage, and times on back
If yes, write type, dosage, and times on back
Leader’s Name:_______________________________
If yes, write type, dosage, and times on back
Phone: ____________________
Phone: ____________________
May Tylenol/Advil be given to your child ? No Yes
May Tylenol/Advil be given to your child ? No Yes
Yes
May Tylenol/Advil be given to your child ? No Yes
(circle one)
(circle one)
(circle one)
In event of a serious emergency, _________________________
List allergies
List allergies
List allergies
:_____________________________________________________
:_____________________________________________________
In event of a serious emergency, ______________________
:_________________________________________________
will be contacted and then she/he will notify parents.
Photo and Website Use Release: I authorize the use of any pictures taken
Photo and Website Use Release: I authorize the use of any pictures taken
Photo and Website Use Release: I authorize the use of any
of my daughter at this event for the purpose of promoting Girl Scouting.
of my daughter at this event for the purpose of promoting Girl Scouting.
pictures taken of my daughter at this event for the purpose of
Girl Scouts Heart of the Hudson, Inc.
Parent/Guardian
Parent/Guardian
promoting Girl Scouting.
Pleasantville 914.747.3080 New City 845.638.0438
Parent/Guardian Signature __________________________
Poughkeepsie 845.452.1810 Middletown 845.236.6002
Date ________
Kingston 845.790.2326
P0 - 1
(1 page)
Revised 7/10
Revised 4/08
Leader must carry this
Event, Trip, or Activity
Parent Permission Slip
Required for all girls participating Girl Scout sponsored
Parent Name: ____________________ Phone: ____________
activities other than regularly scheduled meetings.
My daughter ____________________has permission to participate
Troop # ______ is planning
__________________________________
in ______________________________ held on ______________
(name of trip, event, or other activity)
(name of trip, event, or other activity)
(day/date)
on _______ _____________
Name of person picking up child:_________________________________________
(day)
(date & year)
Location: ________________ Phone: __________
In case of emergency,
notify: ______________________________ Phone: ___________
_____________
Mode of transportation:
Relationship to girl: _____________________
Departure:
Return:
In an emergency, when either myself or the person named above cannot
Time ___________
Time: _____________
be reached, I hereby authorize the adult in charge to take any action
Place _____________ Place:_______________
believed necessary for the best interest of my daughter, including
emergency room treatment.
Each girl will need:
Cost of event $________
Have there been any changes in your daughter’s health or insurance
Equipment and clothing
carrier since the Health History form was last filled out? No Yes
_________________________________________
If yes, list on back
Leader’s
Will medications be administered during event? No Yes
Name:_______________________________
If yes, write type, dosage, and times on back
Phone: ____________________
Yes
May Tylenol/Advil be given to your child ? No Yes
(circle one)
In event of a serious emergency, _________________________
List allergies
:_________________________________________________
Photo and Website Use Release: I authorize the use of any
Girl Scouts Heart of the Hudson, Inc.
pictures taken of my daughter at this event for the purpose of
Pleasantville 914.747.3080 New City 845.638.0438
Poughkeepsie 845.452.1810, Middletown 845.236.6002
promoting Girl Scouting.
Kingston 845.790.2326
Parent/Guardian Signature ___________________________
Date ________
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