GIRL SCOUT COUNCIL OF NORTHWEST GEORGIA, INC.

PERMISSION FOR A GIRL SCOUT ACTIVITY

Troop # ____________ is planning to attend ___________________________________

Date ________________ Time __________________________________

Location _________________ Phone number: _____________________

_________________ _____________________

Arrangement for Transportation:

Time ________ and place of departure ______________________________

Time ________ and place of return _________________________________

Mode of transportation ___________________________________________

Adults accompanying the girls: _______________________________________

Each girl will need $______ for expenses to cover ________________________

Other equipment and clothing needed: __________________________________

In case of change of schedule or emergency the leader will notify:

_____________________________ ___________________________

(Name) (Phone Number)

Who will then notify the parents or guardians at the number you have listed for emergencies.

_________________________________ _______________________________

(Leader’s signature) (Phone number)

- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -

(Tear off and return this portion to Troop Leader or adult in charge of activity)

My daughter ________________________________has my permission to participate in

___________________________________. I have reviewed her Health History Record

and confirm that all the information is current and correct. I have provided any medications that

my daughter will need to take in the original container with written instructions on when they are

to be dispensed. I give permission to the person trained in First Aid, or another adult in charge

of the activity to administer the medicine as needed.

During the activity, I may be reached at _____________________________________________

(Address)

Phone # __________________ Cell Phone # ______________________

If I cannot be reached in the event of any emergency, the following person is authorized

to act in my behalf: ________________________ ________________________________

(Name) (Relationship to Participant)

______________________________________ _____________________________

(Address) (Phone Number)

________________________________________________ __________________

Signature of parent or legal guardian Date

In addition to this form, a Health History Record completed and signed by the parent

within the current year is required to be on file with the Troop Leader or adult in charge.

I:outdoor:property:permission form.doc 9/25/00