Permission Slip

Date:  

Location:  

Time and place of departure:  

Time and place of return:  

I give permission to the leaders of the above unit to render First Aid, should the need arise.  In the event of an emergency, I also give permission to the physician, selected by the adult leader in charge, to hospitalize, secure proper anesthesia, order injection, or secure other medical treatment, as needed.  I further agree to hold the above named unit and its leaders blameless for any accidents that might occur during this outing except for clear acts of negligence or non-adherence to BSA policies and guidelines.

In case of emergency, I can be reached by phone at ____________ or _____________

If I cannot be reached, please contact __________________ at ______________________

Signed:___________________________________

Date: _________________