Form Pg-0085cw - Permission Form
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2Permission Form
Dear Parent/guardian:
Troop/group # ______________ is planning___________________________________________________________________________________
Dates(s)_____________________________________________________ Time ____________________________________________________
Location____________________________________________________ Phone number(___________)__________________________________
Arrangements for transportation:
Time and place of departure ______________________________________________________________________________________________
Time and place of return _________________________________________________________________________________________________
Method of transportation _________________________________________________________________________________________________
Leaders accompanying the girls:
Name(s) ______________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________
Each girl will need:
Expenses _____________________________________________________________________________________________________________
Equipment and clothing __________________________________________________________________________________________________
In case of unusual circumstances (major delays, etc.), the leader will call:
Name_________________________________________________________ Phone number (______________)____________________________
who will then contact the parents.
_______________________________________________________________
(___________________)_________________________
Leader
Phone number
Detach and return the bottom portion to leader by _________
Only girls with a signed permission form may participate.
My daughter_____________________________________________________________________________________ has permission to
participate in_________________________________________________________________ Date__________________________________
The following information is provided so that the adult in charge may contact a responsible person in case of illness or accident during the activity.
____________________________________________________________________ (____________)_______________________
Parent/guardian
Phone(s)
_____________________________________________________________________ (____________)_______________________
Parent/guardian
Phone(s)
____________________________________________________________________ (____________)________________________
Responsible person other than the above/relationship
Phone(s)
____________________________________________________________________ (____________)________________________
Doctor
Phone
My daughter is in good health and may engage in all activities [ ] yes [ ] no. If no, list any exceptions ________________________________
_____________________________________________________________________________________________________________________
In an emergency situation, an emergency medical technician may need to know the following information regarding my daughter's health (e.g.,
allergies, chronic illnesses, seizures, etc.) ____________________________________________________________________________________
_____________________________________________________________________________________________________________________
Date of last tetanus shot ____________________________
I give my permission for the adult in charge to take my child to a medical facility, if necessary. In case of emergency, if none of the above can be
contacted, I consent to treatment for my daughter under the supervision of and as deemed advisable by a physician licensed under the Medicine
Practice Act. This provides authority pursuant to Section 25.8 of the California Civil Code.
Parent or guardian's signature ______________________________________________ Date ________________________________________
JN:cc
PG-0085CW 7/7/11
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Parent category: Business