TROOP 464

PARENT PERMISSION and MEDICAL RELEASE FORM

 

Activity:    Pt Mugu Campout                                                Tour Leader:  Jeff Harwood

Location:   Pt Mugu Naval Base                                            Dates:       September 20-22, 2013

Emergency Contact:

                                                                Person to Contact:  _Jo Ann Burkhart_______________

                                                                Phone Number:      __818-481-8415__________________

Departure From:     __Dave's House__________                 Return Place: Dave's House

Departure Time:     __5:15 PM (bring dinner or eat before)  Return Time: __1:00 PM_(approx)

____________________________ _______________________________________________________

 

ACTIVITY CONSENT, RELEASE & AUTHORIZATION TO TREAT MINOR

 

Scoutís Name:  ___________________   Home Phone: ______________ Cell Phone: _____________

 

Activity:  _ Pt Mugu                                                                             Patrol Name ___________________

Date:    From __9/20___To _9/22/13____                         Amount Paid:   _$40

 

Parent Participating:     Yes____ No____                                        Parent Driving     Yes___ No ____

 

RESTRICTIONS AND SPECIAL CONDITIONS: (VERY IMPORTANT)

 

My son takes (describe medication):                                                        Time & Quantity:

(Medication will only be administered by an adult leader)

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            I, the undersigned, being a parent or legal guardian of _____________________ a member of the Boy scouts of America, Troop 464, do hereby give my consent and permission for him to be transported to and from and participate in the above described activity at the time and place set forth above.  In consideration of the benefits to be derived from the aforesaid activity, I hereby voluntarily waive any claim against the local Boy Scout Council, National Council, Local Unit, its sponsoring institution, all Scout Leaders and the owner and driver of the car(s) in which my son is to receive transportation to and from said activity from any and all causes which may arise in connection with said trip or any phase or part thereof.

            I hereby authorize any authorized adult leader of Troop 464 into whose care the above mentioned scout, has been entrusted, to consent to and agree to pay for medical, dental, surgical, or hospital care, treatment or diagnosis for the above mentioned scout under Section 25.8 of the California Civil Code, or its successor statute.

            The authority granted by this authorization includes the authority to consent to and agree to pay for any medical, dental, surgical, or hospital diagnosis, treatment, or care to be rendered to or for _________________, under the general or special supervision of a qualified physician, surgeon, or dentist.

            I further authorize any authorized leader of Troop 464 to receive physical custody of ___________________.  Under Section 1283 (a) of the California Health and Safety Code upon completion of any treatment, and I specifically instruct any treating health facility to surrender the physical custody of _________________ to any authorized adult leader of Boy Scout Troop 464.

            This authorization is given pursuant to the provisions of Section 25.8 of the Civil Code of California.

 

DATED THIS _____DAY OF __________, 2013  SIGNED: ___________________________________