Girl Scout Trip and Special Event permission slip

Troop # ________ is planning a trip or special activity

Activity________________________  Date _______________   Location ____________________________

Place of Departure/return________________________________________________________________

Leave time_________________________  Return time ______________________

Cost per girl  $__________ for ______________________________________________

Remarks____________________________________________________________________

tear here

________________________________________________________________________________________________

Girls name _________________________  Activity ____________________________________

I do (      )      do not (     )  give permission for my child to participate in this activity

I do (      )      do not (     )  give permission for photographs or videos of my child to be used for Girl Scout publicity.

Allergies/medications/remarks _______________________________________________________________

I give permission to the leaders or agents of the Girl Scout Council of Central New York to obtain and administer such medical aid, including that of a licensed medical doctor as might be required, for the immediate care of my child in an emergency.

____________________________________________________       _______________________________

signature of family Adult/Guardian                                                                    Date

(       )   I can help with transportation.  My car can accommodate  ________________ passengers (number of seats with seat belts) in addition to driver.

Emergency Contact (if family adults cannot be reached)

Name ____________________________________________  Telephone _________________________________