Outing: Klondike Derby Dates of Outing: February 6 to 8, 2004

As the parent/legal guardian of Boy Scout ____________________________, I give my permission for him to go on the outing listed above.

I request that in my absence the above named Scout be given medical treatment or admitted to any hospital or medical facility as needed for diagnosis and treatment. I request and authorize physicians, dentists and staff, duly licensed as Doctors of Medicine or Doctors of Dentistry or other such licensed technicians or nurses, to perform any X-ray or diagnostic procedures, treatment procedures, or surgical procedures for the above Scout.

Known allergies and reactions of this Scout, including any allergies to medicine:

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Any medications the Scout needs to take during the outing. I give permission to adult leaders to administer this medication.

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Names of Parents/Guardians: _____________________________________________________

Phone: H_____________________ W____________________ Cell_______________________

Person to notify if parent/guardian is unavailable_______________________________________

Phone: H_____________________ W____________________ Cell_______________________

Insurance Carrier _____________________________ Policy Number______________________

Signature of Parent/Guardian______________________________________________________