We Remember – May 23, 2014
Forms due Tuesday 5/6/2014
Activity:We Remember Memorial Day Celebration Honoring our Veterans
Camp/Trail: Baltimore National Cemetery (placing flags on the graves of our Veterans)
Meet: 4:30pmEpiphany Lutheran Church (9122 Sybert Drive, Ellicott City)
Return: 9:30pmEpiphany (subject to change)
Cost:
In consideration of the benefits to be derived, and in view of the fact that 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 Venture Scout daughter(s)/son(s)/ ward(s) namely:
First______Middle______Last______
on the activity named above. I agree to her participation and waive all claims against the leaders of this trip, officers, agents and representatives of the Boy Scouts of America, and the sponsor. In the event of an emergency, the Crew leader of the activity named above has my permission to obtain medical treatment for this Venture 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 the Crew.Please select the date you will attend:
( ) Yes, I will attend this activityAdult name(s) ______
( ) Yes, I can drive Total vehicle capacity ___ Car ___ Van ___ Truck ___
( ) Yes, I have insurance coverage that meets or exceeds the minimum state requirements.
______/_____/_____
Signature of parent or guardian MUST BE DATED
EMERGENCY INFORMATION: (In addition to Personal Health and Medical Records)
During the activity listed above, I can be contacted at the following phone numbers:
** Primary ( ______) ______Secondary: ( ______) ______
**In most instances, you will be called with the exact return time, please list numbers to contact you.
This Scout is highly allergic or sensitive to:
What, if any, medication is this Scout taking?
Are there any special instructions for this medication?
Do you want activity leader to carry the medication? ( ) Yes ( ) No
MEDICAL INSURANCE INFORMATION:
( ) Yes, the Health Forms and Insurance Card copies on file are up to date and the most current. I am responsible for providing to the Crew any changes or updates immediately.
Use the back of this form for additional information and for explanation of any other problems the activity leader should be aware of. Incomplete information may cause a delay in medical treatment.
Payment Record: S.A. ______Check Number: ______Date: ______Amount: ______
(Return this TOP section and the attached 2nd page along with payment)
(Retain this BOTTOM section for your information)
Activity:We Remember Memorial Day Celebration Honoring our Veterans
Camp/Trail: Baltimore National Cemetery (placing flags on the graves of our Veterans)
Meet: 4:30pmEpiphany Lutheran Church (9122 Sybert Drive, Ellicott City)
Return: 9:30pmEpiphany (subject to change)
Cost:
Date:5:30pm May23, 2014
For more information contact: Adult POC;Jeff Burt:410-740-4325; C:443-896-2183;,Youth POC; Tessa