Boy Scouts Of America Troop 4 Multipurpose Waiver Form Page 2
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2Westminster Presbyterian Church • Pasadena • California
Delivering the Promise since 1913"
INFORMED CONSENT DOCUMENTS SIGNATURE PAGE
All signatures indicate that those persons signing have read, understand, and agree to all terms as
stated in the Policy on Conduct, Waiver of Liability and Disclaimer, and Parent Consent Forms.
Please complete one informed Consent Documents Signature Sheet for each registered scout you
have in Troop 4.
Scout Name: Last
First
MI
.
Home Phone Number:
:
Father/Guardian Name:
Home Phone:
Work Phone:
Cell Phone:
Mother/Guardian Name:
Home Phone:
Work Phone:
Cell Phone:
Physician Name:
Phone#
Physician Address:
POLICY ON CONDUCT
Scout Signature
Date
Father/Guardian Signature:
Date
Mother/Guardian Signature
Date
WAIVER OF LIABILITY AND DISCLAIMER
Father/Guardian Signature:
Date
Mother/Guardian Signature
Date
PARENT CONSENT
Father/Guardian Signature:
Date
Mother/Guardian Signature
Date
VEHICLE INSURANCE INFORMATION FORM
NAME OF INSURANCED COMPANY: _________________________________________
Vehicle (Year/Make/Model)
# of
License
Insurance (In Thousands)
Belts
Plate #
Per Person
Per Accident
Property
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