Individual Activity Permission Slip Event Permission Slip Step 1 of 4 - Parent, Scout, and Emergency Contact 25% Please complete the Troop Permission Slip below to ensure we have your emergency contact information and other details prior to the upcoming Troop outing/campout. Thank you!Scout’s Name(s) - you may use one form for siblings* First Last has my permission to participate in the Potawatomi District First Aid Meet to be held Saturday, March 2, 2019, at the LDS Stake Center in Wilmette, IL.Parent's Name* First Last Parent's Phone Number*Please enter a number where you can be reached in case of emergency during the trip.Emergency Contact Name*Please provide the name of an adult who will be available in case of emergency during the outing in the event you are not available. First Last Emergency Contact Phone Number* Restrictions*NOTE: The Boy Scouts of America and local councils cannot continually monitor compliance of program participants or any limitations imposed upon them by parents or medical providers. List any restrictions imposed on a child participant in connection with programs or activities below and counsel your child to comply with those restrictions.NoneMedical Conditions*Does the scout have any recurring illnesses, allergies or other significant medical conditions? YesNoMedical Condition DetailIf yes, please describe.Tetanus*Is your son's tetanus shot current?YesNoMedication*Is he taking any medication?YesNoMedication DetailIf yes, please describe reason, dosage, frequency, etc. Transportation*Please check all that apply. I cannot drive either way I will drive my own scout there, but cannot take others I can drive other scouts there I will pick up my scout, but cannot take others I can drive other scouts back to Glencoe I can drive both ways Car CapacityPlease indicate the number of scouts you can transport total, INCLUDING your own scout(s) INFORMED CONSENT, RELEASE AGREEMENT, AND AUTHORIZATION I understand that participation in Scouting activities involves the risk of personal injury, including death, due to the physical, mental, and emotional challenges in the activities offered. Information about those activities may be obtained from the venue, activity coordinators, or local council. I also understand that participation in these activities is entirely voluntary and requires participants to follow instructions and abide by all applicable rules and the standards of conduct. In case of an emergency involving my child, I understand that efforts will be made to contact me. In the event I cannot be reached, permission is hereby given to the medical provider to secure proper treatment, including hospitalization, anesthesia, surgery, or injections of medication for my child. Medical providers are authorized to disclose protected health information to the adult in charge and/ or any physician or health care provider involved in providing medical care to the participant. Protected Health Information/Confidential Health Information (PHI/CHI) under the Standards for Privacy of Individually Identifiable Health Information, 45 C.F.R. §§160.103, 164.501, etc. seq., as amended from time to time, includes examination findings, test results, and treatment provided for purposes of medical evaluation of the participant, follow-up and communication with the participant’s parents or guardian, and/or determination of the participant’s ability to continue in the program activities. With appreciation of the dangers and risks associated with programs and activities including preparations for and transportation to and from the activity, on my own behalf and/or on behalf of my child, I hereby fully and completely release and waive any and all claims for personal injury, death, or loss that may arise against the Boy Scouts of America, the local council, the activity coordinators, and all employees, volunteers, related parties, or other organizations associated with any program or activity.Parent Signature*Typing my name here represents my signature accepting the terms of the above waiver of liability for my child to participate in this Troop 28 outing.My scout has permission to participate in the following activity:I acknowledge that there may be some inherent risks associated with this activity,2019 Spaghetti Dinner SERVICE PROJECT2019 Backyard Nature Center SERVICE PROJECTUntitledNameThis field is for validation purposes and should be left unchanged.