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: ______