Parent Permission Form

PARENT PERMISSION FORM

Troop Leader: Please note that any time a troop meets at a time or location different than their meeting place of record

(regular troop meeting location/time) you must inform your Service Unit Specialist and Membership Services Manager,

and have a signed parental permission form (even if the girls are responsible for getting to that location on their own).

You may choose to use the 3-in-1 Parent Permission Form for multiple locations on one outing. This is not the troop

travel application form. Use this (or the 3-in-1) form when your troop is meeting at a time/location different than your

meeting place of record.

Part I: To be completed by the troop leader.

Troop # __________________________

Activity ___________________________________________________________

Date ______________________

Location _________________________________________________________________________

Phone # ______________________________________

Arrangements for Transportation

Time and place of departure _______________________________________________________________________________________________________________

Time and place of return _________________________________________________________________________________________________________________

Mode of transportation ___________________________________________________________________________________________________________________

Names of accompanying leaders/adult _____________________________________________________________________________________ __________________

Each girl will need

Expenses $ ___________________

Explanation _______________________________________________________________________________

Equipment and Clothing __________________________________________________________________________________________________________________

Additional Remarks

_______________________________________________________________________________________________________________________________________

_______________________________________________________________________________________________________________________________________

In case of an emergency the leader/accompanying adult will contact the at-home emergency contact, whom will immediately notify all parents.

Name ____________________________________________________

Phone _________________________________________________________

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

Part II: To be completed by the parent/guardian and returned to the troop leader. Please keep top portion.

My daughter _______________________________________________________________________________________ has permission to participate in the following

activity ____________________________________________________________________________________________________ with Troop # _____________ on

(date) _______________________________ .

During the activity, I may be reached at: (address) _____________________________________________________________________________________________

(phone) ______________________________________________________________________________________________

If, at any time, I cannot be reached in the event of an emergency, the following person is authorized to act on my behalf ___________________________________

Relationship to participant __________________________________________________

Phone ________________________________________________

Participant’s physician’s name ________________________________________________

Phone _______________________________________________

Additional Remarks ______________________________________________________________________________________________________________________

_______________________________________________________________________________________________________________________________________

_____________________ (Y/N) I authorize Girl Scouts Carolinas Peaks to Piedmont to use photographs of my Girl Scout for the purpose of telling a story or

promoting the interests in publications and on the website (girls’ last names are not used on the website).

Parent/Guardian Signature _______________________________________________________________________ Date ___________________________________

Submission Instructions

This form is an exchange between the troop leader and the parent/guardian.

Revised July 2011