PARENT/GUARDIAN PERMISSION FORM

E-mail Address:
Troop #:                         Age Level(s):
Planning a Trip To:
Date:                   Time:
Location:           Phone #:
Leader's Name:                             Phone #:

---------------------------------------------------------------(Cut off and return below portion to troop leader) ----------------------------------------------------------------------

My daughter ____________________________ has permission to participate in ______________________

_________________________________________________. She is in good physical condition and has not had
any serious illness or operation since her last health examination. During this activity, I may be reached at:

Address: ___________________________________________Phone #: _____________________
If I cannot be reached in the event of an emergency, the following person is authorized to act in my behalf:

Name & address: ____________________________________________________________________

Relationship to participant: ___________________________ Phone #: _________________________

Physician’s name: ______________________________________ Phone #: __________________________

Additional Remarks: _____________________________________________________________________
In addition to this form, a medical history signed by the parent within the current year is required for water sports,
horseback riding, skiing, hiking, noncontact sports, such as tennis or gymnastics, and other such physically
demanding activities. Check with your Council for suggested medical history form.

Signature of Custodial Parent/Guardian ______________________________ Date _________________