TROOP 19 CAVEMAN YOUTH PERMISSION SLIP

DUE BY SAT, DECEMBER 4

has my permission to attend Caveman at Penfield Cabin. I understand that drop

off is at 4:30 PM on Sat, December 4 at Penfield Cabin Read Stuart's e-mail for what to bring, and pick up is at approximately
at 9:00 AM on Sat, December 4 at Penfield Cabin.

I PLAN TO PAY VIA

By my signature below I affirm that I understand that participation in the activity involves a (PAYPAL/SCOUT ACCT/CASH/CHECK:
certain degree of risk. I have carefully considered the risk involved and have given consent for
myself or my child to participate in the activity. I understand that participation in the activity is
entirely voluntary and requires participants to abide by applicable rules and standards of (TYPE ONE)
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. TREASURER SIGNATURE (WHEN PAID):

The following amount is final:

Total Food $5.00
Total Fees (you will be billed) $5.00 PAID IN FULL? Y N

There is no troop carpool for Caveman. Please drive your scout to

Penfield Cabin.
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’s activities.

Applicant will be bringing the following cell phone on the trip:

My home/cell phone numbers are:

Other Phone:

Emergency numbers, if I cannot be reached at Cell, Home or Work:

Contact and Phone Number(s):

Contact and Phone Number(s):

Participant will be bringing the following medication(s):

I know that if participant needs medications during the event/outing, I will need to notify the tour leader in advance and arrange to deliver the
medications, in the ORIGINAL CONTAINERS to the Tour Leader PRIOR to leaving for the event/outing. (initial)
If participant has any special needs or considerations (medications, severe or life threatening allergies, etc.), the Tour Leader needs to know well in
advance. For medications, a doctor’s note is required (prescription on label MAY be sufficient). Additional release forms may be needed.

Date:
X
Printed name: Signed:
(parent/guardian/self if 18+)

Revised 1/20/2011 hds