PARENT/GUARDIAN PERMISSION FORM

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

ARRANGEMENTS FOR TRANSPORTATION:
Time and place of departure:
Time and place of return:
Mode of transportation:
LEADERS ACCOMPANYING THE GIRLS:
Name:                                     Name:
Troop First Aider:           Date Certification Expires:
Each girl will need: EXPENSE:

Other equipment or clothing:

In case of an emergency, the leader will notify the following who will notify the parents:
Name:             Phone #:

Leader’s Signature _______________________________________

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