Fillable Parent Permission Form printable pdf download

Girl Scouts of Southern Illinois

Parent Permission Form

Troop #________ is planning a ______________________________________________________________

on (date) ________________________________ (time)__________________________________________

at (location)___________________________________________ Phone #___________________________

Arrangements for transportation:

Mode of transportation _______________________________________

Time and place of departure___________________________________________________________

Schedule to be followed _____________________________________________________________

Time and place of return _____________________________________________________________

Leaders accompanying the girls:

Name___________________________________ Name____________________________________

Each girl will need _________________________________________________________________________

Expenses________________________________________________________________________________

Other equipment and clothing________________________________________________________________

In case of emergency, the leader will notify _______________________________ Phone #_______________

who will immediately notify the parents.

Leader’s Signature________________________________________ Phone #_________________________

Tear off and return to troop leader by_________________________________________________________

My daughter _____________________ has permission to participate in _____________________________.

She is in good physical condition and has not had any serious illness or operations since her last health

examination. During the activity, I may be reached at (phone #)____________________________________,

(address)_______________________________________________________________________________.

If I cannot be reached in the event of an emergency, the following person is authorized to act in my behalf:

Name__________________________________________________ Phone #__________________________

Address_________________________________________ City________________________ Zip__________

Relationship to participant___________________________________________________________________

Physician’s Name______________________________________________ Phone #____________________

Additional remarks_________________________________________________________________________

If I am asked to be a driver for this event, I verify that I have a valid drivers license, my vehicle is properly

registered, I have at least the state required amount of liability insurance (Illinois $20,000 bodily injury, $40,000

each accident and $15,000 property damage), and my vehicle is equipped with a first aid kit and other state

 Yes

 No

required safety equipment and is in good working order.

If no, please explain: _______________________________________________________________________

I  have  have not provided an appropriate child passenger restraint system for use in

transporting my daughter who is under the age of 8. (Not applicable for girls age 8 and over.)

Parent / Guardian Signature_________________________________________ Date____________________

GSSI: FormsFlash/Parent Permission 92409

Parent Permission Form