(Print, Complete, Sign and Send form to troop leader or event coordinator.)

My daughter _________________________________ has permission to participate in

(Name of Event and Date)
She is in good physical condition and has not had any serious illness or operation since her last health examination.
During the activity, I may be reached at:
Address: __________________________________________________
If I cannot be reached in the event of an emergency, the following person is authorized to act in my behalf:
Name and address: ________________________________________________________________________
Relation to participant: _____________________________________
Phone #: (_____)_____________________
Physician's name: _________________________________________
Phone #: (_____)_____________________
Additional remarks:

(In addition to this form, a medical history signed by the parent within the current year is required for water sports, horseback riding, skiing, hiking, non-contact sports such as tennis or gymnastics, and other such physically demanding activities. Check with your Council for suggested medical history form.)

Signature of Custodial Parent/Guardian and Date

P-8 Rev. 9/11/00