Parental Permission Form

Name______________________________________ Phone__________________________________

Address ________________________ City __________________ State _______ Zip _________

Troop#__________ Activity ________________________________ Location___________________

Departure Date _____________ Departure Place ______________ Departure Time ___________

Returning Date _____________ Returning Place _______________ Returning Time ___________

I give permission for my daughter ______________________________________ to participate in the activity listed above. I give permission for the agents of Girl Scouts of Southwest Georgia to seek medical treatment if I cannot be reached in an emergency. Girl Scouts of Southwest Georgia has permission to use photographs and/or motion picture or video tapes, in which she appears, and any audio recordings of her voice for publicity purposes. I understand it is my responsibility to transport my daughter to/from the activity location at the listed times. If swimming and/or canoeing are offered, I give permission for her to participate.

Name of Parent/Guardian____________________________________________________________

Signature of Parent/Guardian ___________________________________ Date _________________

Medical Information:

Physician’s Name _______________________________ Phone ________________________

Health Insurance Carrier _____________________________ Policy/Group # _________________

Any specific activities to be restricted? ___________ Specify _________________________________

Parent’s Authorization _______________________________________ (child’s name) has my permission to engage in all prescribed Girl Scout activities except noted above by me. In the event I cannot be reached in an emergency, I herby give permission to a physician to apply treatment and admit my daughter to a hospital if necessary and to notify the following person in my behalf.

Name ___________________________________ Address ____________________________

Day Phone _______________________________ Evening Phone _______________________

Signature of Parent/Guardian ____________________________________ Date ________________