Permission Form - Girl Scouts Of Northeast Texas printable pdf download

Girl Scouts of Northeast Texas

PERMISSION FORM

GS Troop Leader/Advisor please check all that apply (* Requires Activity Approval Notification)

 Day Trip  Overnight *  High Risk *  Sensitive Issue *  Money Earning *

GENERAL INFORMATION: All activities will be conducted in accordance with the GSUSA and GSNETX Policies and

Procedures regarding safety and adult supervision. Retain the top portion of this form for your records.

For High Risk Activities:

GS Troop/Group # Activity Date Start

Activity Date End

Each child should bring:

For programs that include horseback

riding, white water rafting, canoeing,

caving, rock climbing, rappelling,

Activity

Leader

swimming, or other physically strenuous

or hazardous activities, parent/guardian

should recognize that these activities

can be dangerous and that sometimes

Activity Location

Leader Phone

serious injuries may occur.

( )

For Sensitive Issue Activities:

Departure Time and Place

Emergency Contact

For programs that are highly personal in

nature or rooted in beliefs or values,

e.g., AIDS, Child Abuse, human sexuality

Return Time and Place

Emergency Contact Phone

and religion; parent/guardian should

discuss this activity with their child.

Attendance is optional for all or part of

the activity. However, it is the parent or

Transportation Type

Cost

Complete and return form by

child’s responsibility to communicate

this to the GS Troop Leader prior to the

activity date.

PARENT/GUARDIAN PERMISSION –

Activity Name: ______________ Date: ______

For High Risk Activities:

Return this portion to the GS Leader/advisor by date indicated above.

I have read the Safety Activity

Checkpoints ( ). I

understand that my child will be

I am the parent/guardian of _________________________________________________

exposed to above normal risk of

injury. To the best of my knowledge,

I have read the description of the activity planned for (date) _______________________

my child has the maturity, required

skills, and physical ability to

participate in the activity described

My child will pay the fee of $________________

above.

Initial

Date

I will be responsible for ensuring that my child brings the required equipment and attends

only if in good physical condition.

I give special permission and/or instructions for the following medication(s)___________

____________________________. This medication(s) will be properly labeled in original

container and given to the adult First Aider.

For Sensitive Issue Activities:

Parent/Guardian: ____________________________________ Phone ______________

I have read the Safety Activity

Parent/Guardian: ____________________________________ Phone ______________

Checkpoints ( ). I

understand that my child will be

Emergency Contact:_______________________________ Phone ____________________

exposed to issues and discussion

that are, or could be, considered to

I have provided medication(s) for my child to take with the supervision of the GS Leader/

be of a sensitive or controversial

nature. I have discussed this activity

First Aider:  yes  no (attach a list if necessary – must be in original container)

with my child and am confident of her

Medication

Dosage

How Often

maturity/ability to participate.

Initial

Date

I give my permission for my child to participate:  yes no

Signature ________________________________________ Date _____________________

Note: If this is a high risk or sensitive issue, please initial and date the appropriate box.

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Permission Form - Girl Scouts Of Northeast Texas

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