Troop119 Permission Form 2016
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TROOP 119 Event Permission Slip
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I Give My Permission for:
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To Attend:On:
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In case of emergency involving my child, I understand every effort will be made to contact me. In the event I cannot be reached, I hereby give my permission to the medical provider selected by the adult leader in charge to secure proper treatment, including hospitalization, anesthesia, surgery, or injections of medication for my child. Medical providers are authorized to disclose to the adult in charge examination findings, test results, and treatment provided for purposes of medical evaluation of the participant, follow-up and communication with the participant’s parents or guardian, and/or determination of the participant’s ability to continue in the program activities.
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I understand that participation in Scouting activities involves a certain degree of risk and can be physically, mentally, and emotionally demanding. I have carefully considered the risk involved and have given consent for myself or my child to participate in this activity. I also understand that participation in this activity is entirely voluntary and requires participants to abide by applicable rules and standards of conduct. I release the Boy Scouts of America, the local council, the activity coordinators, and all employees, volunteers, related parties, or other organizations associated with the activity from any and all claims or liability arising out of this participation.
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No Restrictions Special Considerations or Restrictions:
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Annual Health Form Parts A and B, with copy of Health Insurance Card is to be filed with Troop!
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EMERGENCY NAMES AND PHONE/CELL PHONE NUMBERS:
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PARENT/GUARDIAN:PHONE NO:
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OTHER CONTACT:PHONE NO:
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PHYSICIAN:PHONE NO:
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In the event that he is taking medication (long term or short term), I certify that he is sufficiently knowledgeable regarding the self-administration of his own medication, including correct dosages, administration schedule, and potential side effects. I agree to assume responsibility regarding his ability to administer his own medication while on the trip.
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MedicationDosagePotential Adverse Effects
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OTC Medications: Permission for the Event Leader to administer aspirin-free Over The Counter (OTC) medications (such as Tylenol, Benadryl, Advil, Claritin, Tums, cough/sore throat treatments, topical ointments etc.) to my son in accordance with their judgment, following dosage information on the applicable product.
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I Give Permission
I Withhold Permission
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OTC Medication Exceptions:
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Allergies:
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(Additional allergies and medications should be attached)
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Troop 119 assumes no responsibility in administration of medications. Event Leader must be made aware of all medications in case of emergency. Failure to comply with these specifications can result in dismissal of the Scout from Troop activities.
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PARENT/GUARDIAN SIGNATURE
DATE:
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