PERMISSION SLIP

                     BSA TROOP 510  ~  MOUNTAIN-LAKE DISTRICT    

SCOUT’S NAME ________________________________________   Home Phone _________________________

 I give my permission for my Scout to go on an overnight trip with Troop 510.  I understand they will be going to:  

________________________________________, departing on ________________  ____,  200__, at _____   __M.

 They expect to return on __________________________  ____, 200__, at approximately _____  __M.

 My child has no physical problems, limitations, or allergic reactions (except those listed below), that the adult leader should be aware of in terms of my child’s participation in the troop’s activities.

 ___________________________________________________________________________________________

 Any condition (s) now requiring regular medication? ___________________________________________________

 Dosage _____________________________________________________________________________________

 Dosage _____________________________________________________________________________________

 I give permission to the troop leader in charge of the activity to administer as per the dosage indicated, the medications listed above.  In addition, by checking below, I give permission for the following non-prescription medications/ointments to be administered by the troop leadership as may be necessary for the comfort of my child:

 □  Aspirin    □  Tylenol    □  Advil    □  Anti-bacterial Oint    □  Sunburn Oint    □  Hydrogen Peroxide  □  Antacid    □  Sting-Eze   

In case of Emergency, Please Notify;

Name:  _____________________________________________   Relationship: __________________________________

Work # ____________________________________________    Home #  _____________________________________

Cell #   _____________________________________________   Pager #  _____________________________________

Alternate Contact:  ____________________________________   Relationship: __________________________________

Contact Phone: _______________________________________  Other: _______________________________________

 In case of emergency, I understand every effort will be made to contact me (if an adult, my spouse or next of kin). In the event I cannot be reached, I hereby give my permission to the physician selected by the adult leader in charge to secure proper treatment, including hospitalization, anesthesia, surgery, or injections of medicine for my child (or for me, if an adult).

  Signature of Parent or Guardian  ___________________________________________   Date:__________________

 Comments: __________________________________________________________________________________