Boy Scout Troop 510

Permission Slip

Outing:

Date:

Leave:

Return :

Leader:

Notes: ______________________________________________________________

Please return Permission Slip with money... No Slip No Go!

I give my permission for ___________________________ to attend _______________

X_________________________________

Parent or guardian

Health History (Check any that apply)

Illness Allergies

Ear Infections____________ Penicillin____________

Convulsion______________ Poison Ivy___________

Diabetic_________________ Insect Stings__________

Asthma_________________ Other_(Specify below)

________________________________________________________________________________________________________________________________________________

Medications presently being taken, their dosage, and times given....

Medication______________________________________________

Instructions_____________________________________________

All Medications are to be given to the leader at the campout!

I hereby give permission for emergency medical treatment in the event I am unable to be reached.

X_________________________________

Parent or guardian

My Phone Numbers are...__________________________________________________

Please give the name and phone number of another person to call if you are not available:

Name__________________________ Phone_______________ Relationship__________