Print Form
Permission Slip
MUST BE COMPLETED AND RETURNED
TO LEADER PRIOR TO PARTICIPATION
Troop No.:
is planning a
Date:
Time:
to:
Location:
Phone:
Arrangements for Transportation ‐ If transportation is part of the troop trip, drivers must be registered, approved adult
volunteers who have completed the volunteer application and background check process.
If not part of the troop trip, indicate “transportation on own” and families are responsible for arranging their own
transportation.
Time and Place of Departure:
Time and Place of Return:
Mode of Transportation:
Leaders Accompanying Girls
Name:
Name:
Each Girl Will Need:
Expenses:
Other Equipment and Clothing:
In case of emergency, the leader will notify:
who will notify the parents.
Phone:
Leader’s Signature:
Phone:
…………….…..…..….….……Tear Off & Return to Troop/Group Leader, Prior to the Activity……..…………..………………………
This form will accompany the responsible adult for this approved Girl Scout activity.
My Girl Scout,
, has permission to participate in
1. □ She is in good health and can participate without any accommodations.
2. □ She can participate with reasonable accommodations in respect to health or physical special needs.
List special needs:
3. During the activity, I may be reached at:
Address:
Phone:
4. If I cannot be reached in the event of an emergency, the following person is authorized to act on my behalf.
Name and Address:
Relationship to Participant:
Phone:
Physician’s Name:
Phone:
Emergency Medical Care Authorization: In the event of an emergency, I give my consent for emergency medical
treatment as is deemed necessary. I understand that this authority will be exercised only if reasonable attempts to
contact me should fail. I authorize (adults):
or
to act on my behalf to select and authorize a physician or a hospital to give emergency care.
5. I consent that my Girl Scout may be photographed, videotaped, and/or recorded and the images/recordings may be
□ Yes
□ No
made public in newspapers, TV, radio, Internet or other media.
Parent/Guardian Signature:
Date:
A Health History is required for physically demanding activities such as skiing, hiking, horseback riding, etc.
NOTE TO LEADER:
Rev. 7/2013