WESTERN L. A. COUNTY COUNCIL TROOP 464, WOODLAND HILLS

BOY SCOUTS OF AMERICA SCOUTMASTER: ALEX BALIAN

TROOP 464

PARENT PERMISSION SLIP

Activity: ____________________________________________

Location: ____________________________________________

Dates of Activity: _____________________________________ Activity Cost: $ _____________

Transportation: _______________________________________ Extra Money: $ ____________

Leader’s Name: _____________________ Emergency Contact: ________________________________

phone #: ( ___ ) ______________________

Departure from: _____________________ Departure time: _____________________

Return pick-up place: _________________ Return time: ________________________

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ACTIVITY CONSENT, RELEASE & AUTHORIZATION TO TREAT MINOR

Boy’s Name: _____________________________________ Patrol: ___________________

Activity: ____________________________ Location: __________________________

Dates if Activity: from ______ to ________ Fees Enclosed: $_____________________

Parent Participating YES NO Parent can drive YES NO

Parent / Guardian’s Emergency Phone Number ( ___ ) _____________________________

RESTRICTIONS AND CONDITIONS

My son is on medication (describe) ______________________ Time & Quantity __________________

My son has the following medical or physical restrictions _____________________________________

____________________________________________________________________________________

RELEASE FROM LIABILITY & AUTHORIZATION TO TREAT MINOR

I, the undersigned, being a parent or legal guardian of ________________________________ a member of the Boy Scouts of America, Troop 464, do hereby give my consent and permission for him to be transported to an from and participate in the above described activity at the time and place set forth above. In consideration of the benefits to be derived from the aforesaid activity, I hereby voluntarily waive any claim against the local Boy Scout Council, National Council, Local Unit, its sponsoring institution, all Scout Leaders and the owner and driver of the car(s) in which by son (ward) is to receive transportation to and from said activity for any and all causes which may arise in connection with said trip or any phase or part thereof.

I do hereby authorize and consent to any x-ray examination, anesthetic, medical or surgical treatment rendered by any member of the medical or emergency room staff licensed under the provisions of the Medicine Practice Act, or a Dentist licensed under the provisions of the Dental Practice Act and on the staff of any acute general hospital holding a current license to operate a hospital from the State of California Department of Public Health.

It is understood that this authorization is given in advance of any specific diagnosis, treatment of hospital care deemed advisable by the aforementioned physician in the exercise of his best judgment. It is understood that effort will be made to contact the undersigned prior to rendering treatment to the patient, but that none of the above treatment will be withheld if the undersigned cannot be reached.

This authorization is given pursuant to the provisions of section 258 of the Civil Code of California.

DATED THIS ____ DAY OF __________,2000 SIGNED _________________________________