Boy scout permission slip

Kiwanis Service Project – Saturday, March 1, 2014
Helping the Kiwanis, our troop sponsor, with putting on a breakfast for counselors for the annual middle school Youth 2 Youth conference 6:30 a.m. – 8:30 a.m., Saturday, March 1, 2014.
Logistics: Scouts should be dropped off and picked up at Dougherty Valley HS
Uniforms: Wear Class A uniforms
Parking lot of Dougherty Valley High School by administration building

Kiwanis will provide food to be served and necessary supplies Project will involve setting up a breakfast for conference counselors, serving the food and finally cleaning up after breakfast Breakfast will be available for scouts too Questions: Mr. Matsunaga, phone: (925) 838-1617 or email
ASM’s for day of the outing will be Mr. Carstensen and Mr. Oki Return the permission slips to your Patrol Leader.
Patrol Leaders submit the collected slips to the outing folder no later than the Troop Meeting on Tuesday, February 25
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INFORMED CONSENT, RELEASE AND PERMISSION TO TREAT Kiwanis Service Project – Saturday, March 1, 2014
Troop 805. I understand that participation in Scouting activities involves a certain degree of risk and can be physically, mentally, and emotionally demanding. I have carefully considered the risk involved and have given consent for myself and/or my child to participate in this activity. I also understand that participation in this activity is entirely voluntary and requires participants to abide by applicable rules and standards of conduct. I release the Boy scouts of America, the local council, the activity coordinators, and all employees, volunteers, participants, related parties, or other organizations associated with the activity from any and all claims or liability arising out of this participation. If this activity involves archery or firearms, I hereby give express consent for a qualified range instructor to furnish BSA-approved archery or firearm equipment to the participant for the purpose of instruction in the safe handling and use of such equipment and related activities at designated ranges. I hereby give permission for the adult leaders to give over-the-counter (OTC) medicines as needed (e.g. Aleve for headache, fever, inflammation, pain; Benadryl for allergic reactions, nasal allergies, hives and itching; Lomotil for diarrhea; etc.) In case of emergency involving my child, I understand every effort will be made to contact me. In the event I cannot be reached, I hereby give my permission to the medical provider selected by the adult leader in charge to secure proper treatment, including hospitalization, anesthesia, surgery, or injections of medication for my child. Medical providers are authorized to disclose to the adult in charge examination findings, test results, and treatment provided for purposes of medical evaluation of the participant, follow-up and communication with the participant’s parents or guardian, and/or determination of the participant’s ability to continue in the program activities. (All reasonable measures will be taken to safeguard the health and safety of the Troop's members.) Name of Parent or Guardian (please print):
Home Phone:
Cell Phone:
If I cannot be reached in the event of an emergency, please notify the person named below: Cell Phone:
The following information relates to my son: Physician's Name:
Insurance Company:
Policy No:
Allergies or pertinent medical information (incl. Rx & OTC meds):
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