PERMISSION SLIP

BSA TROOP 119 - PEABODY, MA

Scout's Name :_________________________________________________________________

Address:_______________________________________________________________________

My son has permission to attend the following Troop event:

Event: ________________________________________________________________________

_______________________________________________________________________________

Date(s):_______________________________________________________________________

During this event we can be located at the following telephone number(s):
_______________________________________________________________________________

In case of an emergency, we understand that every effort will be made to contact
the parent or guardian of the Scout. 

In the event we cannot be reached, we hereby give permission to the physician
selected by the leader of the Troop to hospitalize, secure proper treatment
for, and to order injection, anesthesia or surgery for our child named above.

Signature:_____________________________________________________________________
(Parent or Guardian)

Date:__________________________________________________________________________

Insurance Company:_____________________________________________________________

Policy Number:_________________________________________________________________

Preferred Physician:___________________________________________________________

Address:_______________________________________________________________________

Phone Number:__________________________________________________________________

Allergies/Other Pertinent Information:
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________