Annual Permission Form
October 1, 20 - September 30, 20
GIRL INFORMATION
Troop #
City
State
Zip Code
Other Phone
Girl Scout's Name
Street
Birth Date
PERMISSION FOR ACTIVITIES
q Yes - Initialed
q No - Initialed
By checking “No”, I am requesting to sign individual permission slips for each activity.
My child has permission to travel to, attend and participate in troop and council-sponsored activities that are (1) a day trip, 2)
not considered high-risk activities as outlined by Girl Scouts of WNY/GSUSA. Leaders will be notifying parents or guardians
of activities planned.
PERMISSION FOR EMERGENCY MEDICAL TREATMENT (AND SHARING HEALTH HISTORY)
q Yes - Initialed
q No - Initialed
In the event of an emergency, every effort will be made to contact a parent/guardian/emergency contact person. If no
contact can be made, I hereby give authorization to Girl Scouts of
WNY
and agents, to seek treatment for my child and/or
dependent minor by a licensed professional or dentist. I know of no reason(s) why my child may not participate in
prescribed activities as noted on the health history form.
If permission for emergency medical treatment is not provided, Girl Scouts of
WNY
shall be released from all liability resulting
from untreated injury or illness and shall be held harmless for the same. If you wish to provide specific, alternative
instructio
ns, ple
a
s
e do so on the back of this form.
If I cannot be reached, the following person(s) can act on my behalf.
Name Phone(s) Relationship
Name Phone(s) Relationship
Complete this form at the initial troop meeting. Troop leader will keep original.
PARENT AGREEMENT
When participating in Girl Scout activities I agree that my child and I will act in a manner that models the ideals and values of
the Girl Scout Promise and Law.
I have read and understand this Annual Permission Form. I may change or revoke any aspect of this agreement at any time by
submitting my request, in writing, to the troop leader.
Printed Name of Parent/Guardian Signature of Parent/Guardian Date
Street Address City, State, Zip E-mail address
Home Phone Work Phone Mobile Phone Other Phone
| 6/29/20
Home Phone
Grade in Fall and
School Attending
Address
GSWNY COVID19 Waiver of Liability
I acknowledge the contagious nature of the Coronavirus/Covid-19 and that the CDC and
many other public health authorities
still recommend practicing social distancing.
I further acknowledge that Girl Scouts of Western New York (GSWNY) has put in place
preventative measures to reduce the spread of the Coronavirus/COVID19.
I understand that GSWNY cannot guarantee that I will not become infected with the
Coronavirus/COVID19. I acknowledge that the risk of becoming exposed to and/or infected by
the Coronavirus/COVID19 may result from the actions, omissions, or negligence of myself and
others, including, but not limited to, GSWNY staff, visitors, and their families.
I voluntarily seek services provided by GSWNY, and acknowledge that I may be increasing my
risk of exposure to the Coronavirus/COVID19. I acknowledge that I must comply with all set
procedures adopted by the Council in an effort to reduce the likelihood of exposure and/or
spread of Coronavirus/COVID19 while onsite.
I hereby release and agree to hold GSWNY harmless from, and waive on behalf of myself, my
heirs, and any personal representatives any and all causes of action, claims, demands,
damages, costs, expenses and compensation for damage or loss to myself and/or property that
may be caused by any act, or failure to act of the Council, or that may otherwise arise in any
way in connection with any services provided by GSWNY. I understand that this release
discharges GSWNY from any liability or claim that I, my heirs, or any personal representatives
may have against GSWNY with respect to any bodily injury, illness, death, medical treatment,
or property damage that may arise from, or in connection to, any services received from
GSWNY. This liability waiver and release extends to GSWNY together with all owners,
partners, and employees.
Signature:_____________________________________________________
Nam
e (please print): _________________________________________
Date: _______________________
Annual Permission Form
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