RETURN THIS PORTION TO LEADER
I understand and am in complete agreement that:
1. my daughter____________________________________ will participate and/or travel with Girl Scouts of Eastern Oklahoma
troop # at/to (location) on (date/s) ;
2. there will be adults participating with/accompanying the Girl Scouts;
3. my daughter will participate in (description of activities) ;
and/or will visit: ;
4. transportation will be by private car rented/chartered vehicle commercial airline other ;
5. the group will stay at (name of overnight facility) and be housed in
lodge cabins connecting rooms tents other ______________________; this facility is locked unlocked;
6. security arrangements made by the troop include __________________________________________________________.
During this activity, I may be reached at the following locations in addition to the home phone:
Additional telephone number(s) – Mother ______________________________________________________________________
Additional telephone number(s) – Father ______________________________________________________________________
In case I cannot be reached, someone to contact in an emergency will be (please notify these people of their responsibilities):
Name ____________________________________ Relationship ______________________ Phone ____________________
Name ____________________________________ Relationship ______________________ Phone ____________________
Private Medical Insurance Information: Company _______________________________ Group # ____________ Other # ____________
After this activity, my daughter(s) will be going __________________________ with ____________________________________
I hereby give permission for the administration of the following medications if deemed necessary by a qualified first aider, nurse or physician. Dosages will be administered
according to directions on the container unless otherwise directed by a physician. Please () check any medication your child MAY be given.
Brand:___________________ Brand:________________
I am sending the following medication(s) with my child:
MEDICATION DIRECTIONS
1. __________________________________________________________ ___________________________________________________________________
2. __________________________________________________________ ___________________________________________________________________
3. __________________________________________________________ ___________________________________________________________________
PARENT/GUARDIAN SIGNATURE: _________________________________________________________________________________DATE: _____/_____/_____
(Signature required if sending/approving any medication.)
By signing this permission document, I acknowledge that I have had an opportunity to discuss all aspects of this activity, I am aware of all security arrangements, I fully
understand the nature of this event and am in complete agreement and have no further questions regarding it. I give my unreserved permission for my daughter to
participate and for the adults to act in a parental role in my place. I understand that the Authorization for Emergency Care, which I signed when my daughter joined the
troop this current year, is in effect for this activity.
X Parent/Guardian SIGNATURE (in ink)___________________________________________________Date _______________________
DON’T FORGET!!
GIRL SCOUT ACTIVITY
GOING TO __________________________________________________________________ ON (date) __________________________
TIME AND PLACE OF DEPARTURE _______________________________________________________________________________
SHE NEEDS TO BRING AND/OR WEAR ____________________________________________________________________________
AT-HOME CONTACT NAME AND PHONE _________________________________________________________________________
PICK HER UP! DAY/DATE: ____________________ TIME: ____________________ PLACE: _____________________________
Clip here and keep this information for reference
DO I NEED TO SEND MONEY?
NO YES! $______________
