Parents Guardians Information Form For Day Or Overnight Trips

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Permission Slip
Girl Scouts of Greater Chicago
Girl Scouts of Greater Chicago
and Northwest Indiana
and Northwest Indiana
Activity Permission and
Parents/Guardians Information Form
Emergency Medical Form
for Day or Overnight Trip(s)
To be completed by the leader:
To be completed by parent/guardian:
Troop #
is planning a trip on (date)
Trip date:
Location:
from (times)
to
.
Return this half of the form to the leader no later than (date)
Location/Destination:
Notice that my Girl Scout will NOT participate in the trip listed
Phone #
 NO, my Girl Scout
does NOT have my
permission and will not participate in this trip.
Leader names and cell phone numbers accompanying the girls will be:
Parent/Guardian signature
Date
Permission for participation (complete and sign where indicated)
 YES! My Girl Scout
has my permission
to participate in the trip indicated above.
Mode of transportation:
 YES! My Girl Scout
has my permission
We will meet at/depart from:
Time:
to participate in the trip indicated above with the following limitations and/or
We will return to:
Time:
reasonable accommodations: (Please describe.)
Activities in which girls will be involved:
Is she taking any medication? If so, please list them below:
During the activity, I (we) may be reached at (Phone):
Each girl will need:
(address)
Expenses:
Mother/Guardian day #:
Father/Guardian day #:
Mother/Guardian eve #:
Father/Guardian eve #:
Clothing:
Family Physician:
Phone #:
If I (we) cannot be reached in the event of an emergency, the following person
Equipment:
is authorized to act in my (our) behalf:
Name:
Address:
In case of emergency or delay, the leader will notify:
Phone #:
Relationship:
I will permit photographs of my Girl Scout to be taken at this event to be used
Address:
for publicity by authorization of the designated members of the council. I do
Phone:
herewith authorize the treatment by a qualified and licensed medical doctor of
who will notify parents.
my Girl Scout
in the event of a medical
emergency which, in the opinion of the attending physician, may endanger her
life, cause disfigurement, or physical impairment or undue discomfort if delayed.
It is understood that effort shall be made to contact the undersigned prior to
rendering treatment, but that any of the treatments will not be withheld if the
Signature of leader accompanying girls
Date
undersigned cannot be reached.
* Parents/Guardians: BE SURE YOU HAVE DETACHED THIS HALF OF
THE ACTIVITY PERMISSION FORM. IT IS FOR YOUR INFORMATION.
Parent/Guardian signature
Date
Print Form
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