My daughter _____________________________ has my permission to participate in __________________________ on _______________________________. She is in good health and has not had any serious illness or operations since her last health exam. She may engage in any planned activities, except as noted on back of this permission slip.
My signature also indicates permission to take photographs and use them for publicity purposes. If you do not want photos taken or used in newspapers or a display, please indicate here: _____NO
____
I will be driving and accompanying the
girls on this trip. I have _____ seat
belts and will require every passenger
in my vehicle to wear a seatbelt. I have
the minimum vehicle insurance required
by law and I agree not to smoke while I
have Girl Scouts in the vehicle.
During this activity, I may be reached at: Address: ___________________________ Phone ________________________
If I cannot be reached, in the event of an emergency, the following person is authorized to act in my behalf:
Name: ___________________________________________________
Relationship: _____________________________
Address: _________________________________________________
Phone: __________________________________
Physician’s Name: _________________________________________
and phone ________________________________
Last Tetanus Shot (Date Received): ______________________
If none of the above is available, I consent to treatment for my daughter to be secured by the adults in charge.
______________________________ ______________________
Parent/Guardian Signature Date