Form Gssjc F-204m - Girl Scout Permission Slip Multiple Use - Girl Scouts Of San Jacinto

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Use this form ONLY with Girl Scout Medical Information Form (GSSJC F-185)

GIRL SCOUT PERMISSION SLIP – MULTIPLE USE

Girl Scouts of San Jacinto Council

(THIS FORM MAY BE PHOTOCOPIED WHEN COMPLETED. PRINT CLEARLY, USE BLACK INK.)

Girl's Name:

Troop/Group #

Age:

My daughter has my permission to attend the activity/activities listed below. She will not attend if she is not feeling well. I give my permission to have her treated by a licensed

physician if necessary. I also agree to be financially responsible for all expenses associated with providing medical care for my child. My signature on this document also

allows Girl Scouts to use photographs, voice, and/or video of my child for Public Relations purposes. My daughter may have opportunities in the future to attend activities

other than the ones listed on this form. I acknowledge that if I give permission for her to participate in such activities in the future, it is under the same conditions that are set

out in this form, including with respect to transportation. (Leader: Attach future parent permissions to this form.)

Leader should communicate complete information about each planned activity to parent/legal guardian, including activity, location,

date/time, departure time/place, return time/place, cost, dress, what to bring, and other pertinent information.

Activity:

Date:

Activity:

Date:

Activity:

Date:

Activity:

Date:

Activity:

Date:

TRANSPORTATION RELEASE: I understand that troop/group leaders must obtain the written consent of parent/guardian for every girl wishing to participate in an activity

or outing that is held at a different place and time from the regularly scheduled troop/group meeting. I accept responsibility for the transportation of my child to and from any

Girl Scout activity and recognize that transportation to and from Girl Scout events is not the responsibility of Girl Scouts of San Jacinto Council. I recognize that the driver of

any such carpool or bus service that I arrange is not acting as an agent of Girl Scouts of San Jacinto Council. It is my expressed intention to hold Girl Scouts of San Jacinto

Council harmless for any and all injuries, death or damages arising from or in any way related to any such transportation.

I give my permission for my daughter to participate in Boating, Swimming, Horseback Riding, or other strenuous activities. If no exceptions, she may participate in all

activities. EXCEPTIONS:

My daughter may not be released to: __________________________________________________________________________________________________________

If unable to reach me in case of an emergency or change in plans, please contact one of the following. I will make arrangements with these people prior to the event.

Name:

Day:

Evn:

Relationship:

Name:

Day:

Evn:

Relationship:

Medication(s) she can have: _____________________________________________________________________________________________________________

Medication(s) she cannot have:___________________________________________________________________________________________________________

_______________________ will self-administer

Epi-pen