Girl Scouts - Totem Council

ACTIVITY PERMISSION FORM

Please read SECTION A carefully, then complete SECTION B and return it to the
troop/group leader.
______________________________________________________________________
SECTION A - to be completed by  leaders and retained by parent/guardian

Troop/Group: __________ Adult in charge: ____________________________________
Event or Activity: ________________________________________________________
Location: ______________________________________________________________
Departure:  Date _________ Place _____________________________Time _________
Return:       Date _________ Place _____________________________ Time_________
Cost per girl $___________ Each girl is to bring ________________________________
In Case of Emergency, you can reach the troop/group by calling (____)________________
Comments _____________________________________________________________
______________________________________________________________________

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SECTION B - to be completed by parent/guardian and returned to leaders

I permit __________________________to take part in __________________________
                       child’s name                                                event/activity
from ____________________________ to ___________________________________
                      departure date                                              return date
As the parent or legal guardian of the above child, I give permission for:
 1. the above Child to be transported by a volunteer driver.
 2. the troop first aider to give over the counter medications for minor medical discomforts.
 3. the adult in charge to arrange emergency medical attention if I cannot be reached.
 4. the above child to be photographed and/or video taped during the event and I authorize
     the use of images by Totem Council.

The above child is in good health and able to participate.

Her restrictions on strenuous activities are: ____________________________________
She has the following allergies: _____________________________________________
She is taking the following prescribed medication: _______________________________
In case of Emergency, I may be reached in the town of ___________________________
 by calling (_____)________________________ or (_____)______________________
Name of parent or guardian ________________________________________________

Signature X_________________________________________Date: _______________