BSA Troop 93

PARENTAL RELEASE/AUTHORIZATION & YOUTH AGREEMENT FORM

I do hereby hold harmless and release the leaders of Troop 93, agents and representatives of the Boy Scouts of America from any liability for any injuries my child(ren), _________________________________, might receive while participating in activities under the sponsorship of Troop 93. I further authorize the leaders of these activities to admit my child(ren) to any hospital or other medical facility and further authorize them to obtain any emergency medical treatment needed by my child(ren).

I understand and agree the adult in charge of the activity may separate my child from the activity if my child's persistent behavior is judged to disrupt the program or activity and/or to endanger anyone present at the activity, including my child. I understand and agree I will then have to arrange and pay for immediate transportation for my child away from the location of the activity to a location of my choice. If I cannot be contacted, the adult in charge of the activity may arrange for the immediate transportation of my child to his place of residence.

I agree to reimburse Troop 93 for any unexpected or emergency expenses paid on my child's behalf during any activity.

This form to remain effective until revoked in writing by a parent or legal guardian of my child, or until such time as my child ceases to be a registered member of Troop 93.

SIGNED: _________________________________ DATE: _________________

Parent or Legal Guardian

- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -

Please fill out information on back of this form.

MEDICAL INFORMATION

Youth name: ________________________

Name of Parent(s) or Legal Guardian: __________________________

Name of Insurance Company: ________________________________

Policy Number/Group Number: ________________________________

Emergency Contact #: Day _______________ Night _______________

Name & Number to call if parent(s) or legal guardian CANNOT be reached: _____________________________________________________________

Approximate date of last tetanus shot: _____________________

Known Allergies: ____________________________________________________

Other medical/attitudinal information leaders might need to know, including medication:

______________________________________________________________________