Special Permission Form - Girl Scouts Of Central Indiana
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2Special Permission Form
Troop _______________ Date________________ Destination _______________________________________
Address ___________________________________________ Phone (______) __________________________
Briefly describe activities _____________________________________________________________________
___________________________________________________________________________________________
Arrangements for transportation
Time and place of departure __________________________________________________________________
Time and place of return _____________________________________________________________________
Type of transportation _______________________________________________________________________
Leaders accompanying the girls
Name (s) _________________________________________________________________________________
Fees
Troop pays ________________ Girl pays _______________ Optional spending money ___________________
Money due to troop leader by (date) ____________________________________________________________
Each girl will need
Other equipment and clothing _______________________________________________________________
_________________________________________________________________________________________
In case of an emergency
Leader will notify the troop emergency contact person who will immediately notify the parent/guardian.
Emergency contact person __________________________ Phone (______) _________________________
Leader’s signature __________________________________________________________________________
Tear off bottom half and return to troop leader by (date) _____________________________________
My Girl Scout ___________________________________ has permission to attend the Girl Scout trip to
_______________________________________________ and participate in the above described activities.
During the activity, I may be reached at (phone) (________) _____________________________________
If I cannot be reached in the event of an emergency the following person is authorized to act on my behalf:
Name __________________________________________ Phone (_______) ___________________________
Relation to participant ______________________________________________________________________
Address ___________________________________________ City __________________ ZIP ______________
Additional remarks: Please note if your child has any specific limitations and/or special needs, including
medications. Use additional sheet if necessary.
Parent/Guardian’s Signature _____________________________________ Date _______________
� I have read the photo release on the back of this permission form and give my consent. � I do not consent
Parent’s Signature _____________________________________ Date _______________
Each outing requires individually signed permission.
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