I hereby give my permission for my minor child ________________________________ to attend the Boy Scout Troop 79 trip to ____________________________________ on the following date(s) ________________. I understand that the sole function to the trip is educational /recreational and I hereby agree for myself and my child, in consideration of the benefit to my child from participation in this activity, to release Boy Scout troop 79 in Westfield, NJ and its adult leaders, from all and any claims, actions or liabilities for personal injury that may be suffered by my child as a result of participation in this trip. I also release troop 79 and its leaders from any loss of property or damage to property which may result to my property or that of my child which is brought on this trip.
In addition, I hereby agree to indemnify and save harmless Boy scout troop 79 and its adult leaders from and against all losses and claims, demands, payments, suits, and judgments by others by reason of omission or act of my child with respect to the activities of this trip.
I authorize the adult leaders in charge of Boy Scout Troop 79, Westfield
N.J. to consent to an X-ray, examination, antiseptic, medical or surgical
diagnosis or treatment, and hospital care, to be rendered to my minor child
under the general or special supervision and on the advice of any physician
or surgeon licensed to practice in the state of __________________________,
when the need for such treatment is IMMEDIATE, and when efforts to contact
me are unsuccessful.
My telephone number is _______________________
Emergency Contact: Name____________________________
Phone # ____________________
Date__________________________
Signature_______________________________________
Address_______________________________________________________________________
Child’s Doctor ___________________________________ Phone #_______________________
Child’s Allergies (if any) ________________________________________________________
Medicines Your Child is Currently Taking____________________________________________
Other Special Needs _____________________________________________________________