Troop 205 is going on an outing on ____________ and will return on _____________

Time leaving: ___________________ Time returning: _______________

Cost: ______________ Place meeting or departing from: ____________________

Trip to: _______________________________________________________________

If you need to contact your Scout, and only in case of emergency, call ______________

phone # ____________________. It may be difficult to make contact, especially of hiking.

In consideration of the benefits to be derived, and in view of the fact that the Boy Scouts of America is an educational institution, membership in which is voluntary, and having full confidence that every precaution will be taken to ensure the safety and well being of my Scout, namely: _____________________________ on the activity named below, I agree to his participation and waive all claims against the leaders of this trip, officers, agents, and representatives of the Boy Scouts of America, and the sponsor, Ebenezer United Methodist Church. In the event of an emergency, the Troop unit leader of the activity named below has my permission to obtain medical treatment for this Scout at the nearest hospital or doctor, at my expense, if our own doctor is not readily available, and as restricted on the Emergency Data Sheet on file with Troop 205.

__________________________________________________
Signature of parent or guardian, and date

ACTIVITY: _____________________________________________________________

EMERGENCY INFORMATION (IN ADDITION TO PERSONAL HEALTH AND MEDICAL RECORD)

During the activity listed above, I can be contacted at the following phones and will accept long distance calls.

(_______)__________________________ (_______)____________________________

If we are not available call _______________________ relationship ____________________________

at phone # (________) _______________________

This Scout is highly allergic or sensitive to: ________________________________________________

What if any medication is this Scout taking? _______________________________________________

Any special instructions for this medication? _______________________________________________

Do you want the unit leader to carry this medication? ________________________________________

Please use the back of this form for additional information and for explanation of any other problems the activity unit leader should be aware of.

Unit leader in charge of this outing: _____________________________ phone: ___________________