Troop 20/20 Permission Slip - Senior Canoe Trip - June 2018
THIS TRIP IS ONLY FOR SCOUTS IN HIGH SCHOOL.

PLEASE FILL OUT ONE FORM PER SCOUT.  

Note: You will receive an email with your completed form. Please print the PDF and bring it to the next troop meeting with your payment. If you are unable to print the form, please email t2020ct@gmail.com for assistance.

Date: Friday 6/22/2018 - Sunday 6/24/2018
Departure: Friday morning
Return: Midday Sunday
Location: Sleeping at Hurd State Park and Gillette Castle State Park
Cost: TBD but will be minimal ($10 for camping and then food costs)
Permission Slips & Money Due: Thursday 6/7/2018 Troop Meeting
Mandatory certification taking place 6/9 with Mrs. Nolan.
Interested scouts should come to the troop meeting Thursday 5/24 or contact Dan Couture (daniel.s.couture@gmail.com or 860-810-4516).
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Email *
Today's Date *
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Scout's Name *
Scout's Date of Birth *
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Scout's Patrol *
Parent/Guardian's Name *
Parent/Guardian's Phone Number *
Parent/Guardian Participation *
Payment Method *
1st Emergency Contact's Name *
1st Emergency Contact's Phone Number *
2nd Emergency Contact's Name *
2nd Emergency Contact's Phone Number *
Doctor's Name *
Doctor's Phone Number *
Photo/Video Release *
Permission for scout leaders to use photos, videotapes, sound recordings or other electronic representations of my scout on the Troop 20/20 website, Facebook closed group or other scouting publication.
First Aid Administration Permission *
Permission for scout leaders to administer Neosporin, Benadryl, hydrocortisone cream, ibuprofen, Tylenol, Caladryl, aloe or hydrogen peroxide.
BSA 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.

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.
Parent/Guardian's Electronic Signature *
Medical Restrictions *
Please list allergies, medications taken, and any other limitations/restrictions imposed by parents/guardians or medical providers. If there aren't any, then please answer "None".
Drivers Only
Please fill out this section if you are going to be transporting scouts.
Driver's Name
Driver's License Number
Vehicle's Year/Make/Model
Vehicle Owner's Name
License Plate Number
Auto Insurance Liability Limit Requirements Met
At least $50,000 / $100,000 / $50,000
Clear selection
Number Of Scouts Driver Can Transport
Seat Belt Requirements Met
Everyone will be able to be wear a required seat belt.
Clear selection
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