TROOP 746 PARENTS / GUARDIAN PERMISSION SLIP

EVENT:Macaleer Lodge CampWare

DATES:From: Friday January 27, 2017To: Sunday, January 29, 2017

LOCATION:CLOSEST HOSPITAL:

Macaleer Lodge CampWareJennersvilleRegionalHospital

Horseshoe Scout Reservation1015 West Baltimore Pike

Chester County Council, B.S.A.West Grove, PA19390

Peach Bottom, PA17563610-869-1000

717-548-7045**Hospital may change due to availability

COST: Scout $20.00 Scouters $20.00

MEET AT: St. Joe’s Parking LotON: Fri. 1/27/2017AT:6:00 PM We will leave promptly at 6:30PM

RETURN TO: St. Joe’s Parking LotON: Sun 1/29/2017AT:Approximately 12:00 PM

SCOUTMASTER / ADULT LEADER:Erik Leppo 443.725.5618

------Please retain the top portion for your records------

EMERGENCY CONTACT:______PHONE NO.______

Cell ______

Alternate Contact ______ Alternate’s Phone ____________

MY SON ______

FROM: Fri1/27/176:00pm TO: Sun 1/29/17 12:00ish pm LOCATION:St. Joe's

I am ABLE / UNABLE to drive TO / FROM the event. My vehicle can transport ______scouts / scouters including myself. I certify that I have the required (BSA/BAC) amount of auto insurance, my vehicle is in good operating order and that all passengers will have seat belts. I also confirm that I have read and will obey the (BSA/BAC) auto safety requirements.

VEHICLE MAKE:______car / wagon / truck / van TAG No. ______

I am ABLE / UNABLE to participate for the ENTIRE EVENT / FOLLOWING DAYS: ______

In case of an emergency, I understand that every effort will be made to contact me. In the event that I cannot be reached, I hereby give my permission to the physician selected by the adult leader in charge to secure the proper treatment which may include emergency treatment, hospitalization, anesthesia, surgery or injections of mediation to my son.

SIGNATURE: ______Date: / /

MEDICAL / HOSPITALIZATION INSURANCE INFORMATION

List of Medicines and attached directions for use: ______

List of Medicines my son is allergic to: ______

List of items my son is allergic to (bee stings, cats, dogs, hayfever, any foods, rashes): ______

Name of Insurance Company: ______

Policy Number: ______Group No: ______

Name of Insured: ______

Insured Employer Info: ______Tel. No: ______