As the parent or legal guardian of Scout________________, I hereby give my permission for him to participate on the listed outings with Pack/Troop/Crew 139 for the years 2002/2003.

I give permission to the leaders of the above unit to render First Aid, should the need arise. In the event of an emergency, I also give permission to the physician, selected by the adult leader in charge, to hospitalize, secure proper anesthesia, order injection, or secure other medical treatment, as needed. I further agree to hold the above named unit and its leaders blameless for any accidents that might occur during this outing except for clear acts of negligence or non-adherence to BSA policies and guidelines.

Scout _____________________ has the following food, medicine and/or environmental allergies and /or other special needs:

___________________________________________________________________________

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The following steps need to be taken on behalf of my son: __________________________

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Medical Insurance Provider: ______________________

Policy Number/Member Number: _____________________________________________

Please note any special travel or arrival & departure arrangements that need to be made regarding any of the activities including the name and telephone of those authorized to transport your child in your absence: ___________________________________________

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___________________________________________________________________________.

DL# ____________________________ Insurance Company _______________________

Policy Number _________________________ Coverage: _________________________

In case of emergency, I can be reached by phone at ______________ or _______________.

If I cannot be reached, please contact __________________________ at _______________.

Scout Name: ________________ Parent Signature: _______________ Date: ___________

Phone: ________________ Cell Phone: _______________ Pager: _____________________