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Scout Permission Slip
Activity Name _____________________________________________________ For activity dating from _____________________ to _____________________ Scout's Name ______________________________________ Address _________________________________________ City ______________________________________ State _______ Zip _________________ Health/Accident Insurance Co. _________________________ Policy Number ___________________________________
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Have or subject to (check if yes):
__Asthma __Fainting Spells __Convulsions __Allergy to any medication, food __Any condition that may require special care, medication __Diabetes __Heart Trouble __Bleeding Disorders __plant, __animal, or __insect toxin Explain: _____________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ Check here if none of the above applies q Have difficulty with (check if yes) __Eyes, ears, nose, throat __digestion __Bed-wetting __Lung __Sleep walking Any condition now requiring regular medication?________________ Name of Medication______________ Any restriction of activity for medical reasons? Explain________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________
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Parent Authorization
This health history is correct so far as I know, and the person herein described has permission to engage in all prescribed activities, except as noted by me. In the event I cannot be reached in an emergency, I hearby give permission to the physician, selected by the adult leader in charge, to hospitalize, secure proper anesthesia, or to order injection for my son. I will not hold Boy Scouts of America or any of their representatives, including but not limited to, Adult members of Venturing Crew 369, Council Representatives, Sponsoring Institution,... liable for my son/daughter's actions.
Signature _____________________________________________________ Date __________________________________ Home Telephone Number _____________________ Telephone number of relative or neighbor ________________________ I authorize ONLY the following people to remove my son from the activity site: Name Relationship ___________________________________________________________ _____________________________________ ___________________________________________________________ _____________________________________ ___________________________________________________________ _____________________________________ ___________________________________________________________ _____________________________________ ___________________________________________________________ _____________________________________ ___________________________________________________________ _____________________________________
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