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GIRL SCOUT PERMISSION SLIP MULTIPLE USE

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Use this form ONLY with Girl Scout Medical Information Form (GSSJC F-185)
GSSJC F-204M Rev. 08/20
GIRL SCOUT PERMISSION SLIP – MULTIPLE USE
Girl Scouts of San Jacinto Council
(THIS FORM MAY BE PHOTOCOPIED WHEN COMPLETED. PRINT CLEARLY, USE BLACK INK.)
Girl's Name: Troop/Group # Age:
My daughter has my permission to attend the activity/activities listed below. She will not attend if she is not feeling well. I give my permission to have her treated by a
licensed physician if necessary. I also agree to be financially responsible for all expenses associated with providing medical care for my child. My signature on this
document also allows Girl Scouts to use photographs, voice, and/or video of my child for Public Relations purposes. My daughter may have opportunities in the future
to attend activities other than the ones listed on this form. I acknowledge that if I give permission for her to participate in such activities in the future, it is under the same
conditions that are set out in this form, including with respect to transportation. (Leader: Attach future parent permissions to this form.)
Activity: Date:
Activity: Date:
Activity: Date:
Activity: Date:
Activity: Date:
Activity: Date:
TRANS
PORTATION RELEASE: I understand that troop/group leaders must obtain the written consent of parent/guardian for every girl wishing to participate in an
activity or outing that is held at a different place and time from the regularly scheduled troop/group meeting. I accept responsibility for the transportation of my child to and
from any Girl Scout activity and recognize that transportation to and from Girl Scout events is not the responsibility of Girl Scouts of San Jacinto Council. I recognize that
the driver of any such carpool or bus service that I arrange is not acting as an agent of Girl Scouts of San Jacinto Council. It is my expressed intention to hold Girl Scouts of
San Jacinto Council harmless for any and all injuries, death or damages arising from or in any way related to any such transportation.
I give my permission for my daughter to participate in Boating, Swimming, Horseback Riding, or other strenuous activities. If no exceptions, she may participate in all
activities. EXCEPTIONS:
M
y daughter may not be released to: __________________________________________________________________________________________________________
If unable to reach me in case of an emergency or change in plans, please contact one of the following. I will make arrangements with these people prior to the event.
Name: Day: Evn: Relationship:
Name: Day: Evn: Relationship:
M
edication(s) she can have: _____________________________________________________________________________________________________________
M
edication(s) she cannot have:___________________________________________________________________________________________________________
Note: Any medications must be provided in original containers along with a signed note and instructions.
Signature of Parent/Legal Guardian Phone # Pager or Cell Phone Date
_
_____________________________________________________
Print Name of Parent/Legal Guardian
GIRL SCOUT INSURANCE CARRIER: MUTUAL OF OMAHA For confirmation, contact Girl Scouts of San Jacinto Council 713-292-0300 or 1-800-392-4340
Leader should communicate complete information about each planned activity to parent/legal guardian, including activity, location,
date/time, departure time/place, return time/place, cost, dress, what to bring, and other pertinent information.
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signature
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Girl Scouts of San Jacinto Council
Assumption of Risk and Release of Liability – Coronavirus/COVID-19
*Girl’s Name *Troop # *Community
(as she is registered)
I am aware of the highly contagious nature of the 2019 novel coronavirus disease (“COVID-19”) as well as the symptoms,
illnesses, and effects it causes. I am also aware that by participating in any Girl Scouts of San Jacinto Council (“GSSJC”)
activity, I, my daughter, my family, our household members, and those with whom we come into contact could experience
exposure to or infection of COVID-19 as well as its serious effects, which include illness, injury, permanent disability,
and death. I acknowledge that this risk may result from or be compounded by the acts or omissions of others, including
GSSJC employees and volunteers. I understand that while the GSSJC has implemented preventative measures to reduce
the spread of COVID-19, GSSJC cannot guarantee that I, my daughter, my family members, my household members, or
those people with whom we come into contact will not become infected with COVID-19 as a result of participating in
GSSJC activities or while on GSSJC premises.
I am familiar with federal, state, and local laws, orders, directives, and guidelines related to COVID-19, including the
Centers for Disease Control and Prevention (“CDC”) guidance. I will comply with and will ensure my daughter’s
compliance with all such orders, directives, and guidelines while participating in GSSJC activities and while on GSSJC
premises. I further agree that while participating in GSSJC activities and while on GSSJC premises, I and my daughter are
required to follow all GSSJC guidelines, including all COVID-19 instructions, that have been provided to me, whether in
an agreement at the activity or on GSSJC’s COVID-19 webpages. I further understand that any violation of these
guidelines or staff directions may result in me and/or my daughter being asked to immediately cease participation in the
activity with no refund.
I agree that my daughter and I will not participate in any GSSJC activity or come on GSSJC premises if we are
experiencing symptoms of COVID-19 (such as cough, shortness of breath, fever, chills, muscle pain, sore throat, or new
loss of taste or smell); have a confirmed or suspected case of COVID-19; or have had close contact in the last 14 days
with a person who has been confirmed or suspected of having COVID-19. In the event that I and/or my daughter
receive(s) a positive antigen test result for COVID-19 in the next 14 days, I will immediately notify GSSJC by contacting
Melissa Hardy at mhardy@sjgs.org, and I, my daughter, and others members of our household will also refrain from
participating in any in-person GSSJC meetings or activities for at least 14 days after a positive antigen test date, even if
we are asymptomatic.
In consideration of being permitted to participate in GSSJC activities, I, on behalf of myself, my daughter, and any and all
of our beneficiaries, heirs, next of kin, successors, assigns, representatives, and agents, do hereby release, acquit, and
forever discharge Girl Scouts of the USA and GSSJC and each of their respective owners, officers, directors, employees,
agents, contractors, representatives, and volunteers (collectively, “Releasees”) from any and all claims, demands,
liabilities, causes of action, and damages (collectively, “Claims”) related to or arising out of COVID-19, including, but
not limited to, any and all Claims related to or arising out of any COVID-19-related illness, injury, disability, or death
experienced by myself, my daughter, or any other member of our family or household, regardless of whether such
claims are caused, in whole or in part, by the sole, contributory, or concurrent negligence, strict liability, premises
liability, or other tortious or wrongful conduct of Releasees. Notwithstanding the risks associated with COVID-19, I
hereby accept and assume all risks of any COVID-19-related illness, injury, disability, or death experienced by
myself, my daughter, or any other member of our family or household, regardless of whether such risk is caused,
in whole or in part, by the sole, contributory, or concurrent negligence, strict liability, premises liability, or other
tortious or wrongful conduct of Releasees.
By signing below, I hereby certify that I have read and fully understand all of the terms of this Assumption of Risk
and Release of Liability – Coronavirus/COVID-19 (the “Release”) and that I am voluntarily giving up substantial
legal rights, including the right to sue the Releasees as described above. I am voluntarily, knowingly, and
unconditionally signing this Release and hereby agree to all of the terms and conditions of this Release. I represent and
warrant that I have the full legal authority to sign, and am signing, this Release on behalf of myself and my daughter.
Parent/Guardian
Name Signature Date
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GIRL SCOUT PERMISSION SLIP MULTIPLE USE

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Completed 30 March 2021

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