Scout Permission Slip

Activity Name _____________________________________________________

For activity dating from _____________________ to _____________________

Scout's Name ______________________________________

Address _________________________________________

City ______________________________________ State _MA____ Zip ____________

Health/Accident Insurance Co. _________________________

Policy Number ___________________________________

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_____________________________________________________

______________________________________________________________________________________________

______________________________________________________________________________________________

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.

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

___________________________________________________ _________________________

___________________________________________________ _________________________

___________________________________________________ _________________________

___________________________________________________ _________________________

___________________________________________________ _________________________

___________________________________________________ _________________________