Use this form for special troop activities and return to your troop leader before participation.

Instructions:

1. Troop leader fills out Section I.
2. Parent/guardian fills out Section II and returns to troop leader before participation.

 Section I

Troop/Group #:   is planning to
Location: Phone Number:

Date:                      Time:
Arrangements for transportation:

    Time/place of departure:
    Time/place of return:
    Mode of transportation:

Leaders accompanying the girls:
    Name(s):

Each girl will need to bring:

                 Expenses/fees: 
     Equipment and clothing:

In case of emergency, the leader will notify the back-home contact person who will immediately notify parents.

     
At-home contact person’s name                                                                                                                                                       Phone Number

 _____________________________________________________________________________ 
Leader’s Signature                                                                                                                                                                             Phone Number

 --------------------------------------------------------------Detach and Return to Troop Leader ------------------------------------------------------------------

Section I

q       Yes, my/our daughter, , has permission to participate in .

q       No, my/our daughter, , has permission to participate in .
                                                                                                                                                                                             

During the activity, I/we may be reached at:
                                                                                    Name
 
Address                                                                                                                                                                              Phone Number
 
Alternate Name/Address                                                                                                                                              Alternate Phone Number
                                                                                 
If I/we cannot be reached in the event of an emergency, the following person is authorized to act on my/our behalf:

Name: Phone Number:
Address:  Relationship to Participant:

Physician’s Name:      Phone Number:

Additional Remarks:

  
Parent/Guardian Signature                                                                                                                                                                   Date