Permission for a Girl Scout Activity

Don’t see your daughter’s name in the form below? That means we’re missing some forms from you! Please fill out the Annual Permission/Health history form, then come back here.

Permission for Girl Scout Activity

If you are human, leave this field blank.

My daughter, *

has permission to participate in *

Parent Info Section

Troop

is planning

Date

Location

Time and place of departure

Time and place of return

Mode of Transportation

Adult 1

Adult 1 Phone Number

Adult 2

Adult 2 Phone Number

Adult 3

Adult 3 Phone Number

Expense

Equipment and Clothing

Emergency Contact Person

Emergency Contact Phone Number

She can participate with reasonable accommodations. Please describe.

During the activity, I can be reached at: *

I will not send my daughter if she is not feeling well and I will inform you that she will not be attending the activity prior to the time of departure.

If I (we) cannot be reached in the event of an emergency, the following person is authorized to act in my (our) behalf:

Name *

Relationship *

Address

City

State/Province

Zip/Postal

Phone Number *

Your Physician's Name

Physician's Phone

In the event I cannot be reached in an emergency, I hereby give my permission to the physician, hospital or medical service selected by the leaders to hospitalize, secure proper treatment for, and to order injection, anesthesia or surgery for my child as named above. It is understood that a conscientious effort will be made to locate me or the emergency contact listed before any action is taken.

Signature *

Draw It
Type It
Clear

Address

Phone Number

Payment *

I want to mail a check to 28555 Memorial Park Way, Conifer CO 80433.

I will pay in person at some point.

I will pay online. (10% convenience fee)