Troop 174 B.S.A, Yorktown Heights N.Y. Grace Lutheran Church  3830 Gomer St.  Yorktown Hgts. N.Y.  10598

As the parent or legal guardian of ____________________________________,
I hereby give my permission for him to participate in an outing with Troop 174.
 
 

Date of Outing:__________________
 

Location:__________________________________________
 

I give permission to the leaders of the above unit to render first aid, should the need arise. In the event of an emergency, I also give permission to the physician, selected by the adult leader in charge, to hospitalize, secure proper anesthesia, order injection, or secure other medical treatment, as needed. I further agree to hold the above named unit and its leaders blameless for any accidents that might occur during this outing except for clear acts of negligence or non-adherence to BSA policies and guidelines.
 

In case of an emergency, I can be reached by phone at (______)___________ or

(______)_____________.   If I cannot be reached, please contact

________________________________ at (______)_____________.
 
 

Signed: ______________________________________ Date:_______________
                              (Parent or Guardian)

5/19/2003