BSA Troop 256 Permission Slip

I, the undersigned, being the Parent and/or Legal Guardian of __________________________________ do hereby release Boy Scout Troop 256, its agents, officers, and representatives of any and all liability or damages sustained by the aforesaid minor child as a result of injuries or damage sustained by or occasioned to such minor child while participating in:

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including travel to and from, or during said activity, whether or not such injuries or damages are as a result of the negligence, fault, or wrong-doing of Troop 256. I do hereby, on behalf of the aforesaid minor child, consent to such medical treatment and procedures, including surgical and therapeutic procedures as may be necessary to treat and/or remedy any injuries or ailments of any kind suffered by the aforesaid minor child while participating in the aforementioned activity or trip. No additional consent shall be necessary to authorize any such necessary medical treatment, including surgical and therapeutic procedures, but, in the event that any doctor, hospital or treating person or facility shall require additional consent, I do hereby, on behalf of the aforesaid minor child, grant unto Troop 256, its agents, officers, and representatives the right to consent to such medical treatment, including medical and therapeutic procedures, and do hereby indemnify and hold harmless Troop 256, its agents, officers, and representatives from any and all liability or obligation that may arise as a result of the performance of such medical treatment if ultimately deemed necessary.

Executed this __________day of ________________, 200______.

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Parents Signature Emergency Phone Number

While participating in the Scouting activity, I promise to show good Scout Spirit by cooperating with my adult leaders and brother Scouts at all times.

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Scout's Signature

If volunteering to help transport, please provide the following auto insurance information for filing our tour permit (needed only if not previously provided for inclusion in the Vehicle Information - Attachment to Local Tour Permit Application, or if information previously provided has changed):

KIND, YEAR, AND MAKE OF VEHICLE	# PASSENGERS	OWNER’S NAME	DRIVERS LICENSE NUMBER	WILL EVERYONE WEAR A SEAT BELT?	PUBLIC LIABILITY INSURANCE COVERAGE
					PUBLIC LIABILITY		PROPERTY DAMAGE
					Each Person	Each Accident

Activity Fee: $ ____________ Paid: $ _________________