ࡱ> 3523 { bjbj}+}+ "*AAa l<<<<<<<P 8B N \P1> " $o f<  <<  < <    t<<t u5P "tt<01t t PP<<<<(Event Name) (Event Date) Troop Nine, Wilmette, IL www.troopnine.com Permission Form Signup Deadline: (Deadline Date) Form and payment due (Due Date) Camp Out Fee: $XX/Scout In consideration of the benefits to be derived, and in view of the fact that the Boy Scouts of America is an educational institution, membership in which is voluntary, and having full confidence that every precaution will be taken to ensure the safety and well being of the scout son(s) / ward(s), and the following adult & child members of our family: Name and AgeName and AgeName and Age I am willing to drive ____________ Scouts. Drivers: Please provide cell phone number:_______________________ On the above activity, I (we) agree to his/her/their participation and waive all claims against the leaders of this trip, officers, agents, and representatives of the Boy Scouts of America, and the sponsoring institution, the Community Church of Wilmette. In the event of an emergency, the troop unit leader of the activity named above has my permission to obtain medical treatment for this scout(s) or Family member(s) at the nearest hospital or doctor, at my expense, if own doctor is not readily available, and as restricted on the emergency data sheet on file with Troop Nine, Wilmette, Illinois. Signed_________________________________________________Date___________ (see reverse side for important information) Troop 9 Permission Form Emergency Information During the activity listed above, I can be contacted at the following telephone numbers, and will accept long distance calls. Phone #1 HomePhone #2 OfficePhone #3 Cell This scout / family member is allergic or sensitive to: NameSubstanceNameSubstanceNameSubstance What medication, if any will be taken? Include dosage, frequency, and time of day. NameMedicationNameMedicationNameMedication Any special instructions with the medication? No / Yes If yes, please specify:  Do you want the leader to carry the medication? No / Yes Use additional space to provide any other information or explanation of any other conditions about which the activity leader should be knowledgeable;  Date of the most recent tetanus shot / booster: ___________________________ Medical insurance provider information: Insurance Carrier NamePolicy Number Other information, which may be important:  PAGE  PAGE 1 %&'(5678EF h i l m C D V W i j . / 1 2 _ ` a b h i j l m s t u v w { 0JmHnHu0J j0JU5CJOJPJQJ\^JPJCJOJPJQJ^J5CJ$OJPJQJ\^J6 4FVz%&81$$Ifl,""64 la1$$Ifl,""64 la$If$a$a z &'(5678EFGr  X 881$$Ifl,""64 la1$$Ifl,""64 la$IfX Y 4 E W h i j k l m yy~$$IflF 5u"?M066    4 la$Ifm n o fH$$Ifl\,"< |064 la$If 1 6 7 hHhff$$Ifl\,"< |064 la$If 7 B C D I J U V W \ ] h i hLhL$$Ifl\,"< J064 la$If i j k nlllf$If$$Ifl\,"< J064 la $IfZ$$IflI,""064 la . $IfZ$$Ifl,""064 la. / 0 1 2 3 ^ _ $Ifk$$Ifl0u" 0664 la_ ` a j k l w x y z { &`#$Z$$IflN,""064 la 1h/ =!"#$% i8@8 NormalCJ_HaJmH sH tH <A@< Default Paragraph Font<Z@< Plain TextCJOJQJ^JaJ, @, Footer  !&)@& Page Number{ * 4FVz%&'(5678EFGrXY4EWhijklmno167BCDIJUVW\]hijk . / 0 1 2 3 ^ _ ` a l w x | 0000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000@0@0@0 { &X m 7 i . _ { z  !!ta y | za y |  hxz{j<DMV_g  ` |  John F. Phelan]C:\Documents and Settings\JOHN PHELAN\My Documents\troopnine\2007-12 Evil Cave Permission.docJohn F. PhelannC:\Documents and Settings\JOHN PHELAN\Application Data\Microsoft\Templates\Troop 9 Permission Form (Blank).dotJohn F. PhelanaC:\Documents and Settings\JOHN PHELAN\My Documents\Word\Forms\Troop 9 Permission Form (Blank).dotJohn F. PhelanaC:\Documents and Settings\JOHN PHELAN\My Documents\Word\Forms\Troop 9 Permission Form (Blank).dotJohn F. PhelanaC:\Documents and Settings\JOHN PHELAN\My Documents\Word\Forms\Troop 9 Permission Form (Blank).dot%&'(5678EF4EWhijklm167BCDIJUVW\]hij . / 0 1 2 ^ _ ` | @f{ @UnknownGz Times New Roman5Symbol3& z ArialG5  hMS Mincho-3 fg?5 z Courier New"hB#&[U!r0d~ 2HXPermission FormWJohn F. PhelanOh+'0 ,8 T ` l xPermission FormW$Troop 9 Permission Form (Blank).dotJohn F. Phelan4Microsoft Word 9.0@@Ұ@Jo N@<5[՜.+,0  hp  Abbott Laboratories PPD~ # Permission Form Title  !#$%&'()+,-./014Root Entry FD561TableWordDocument"*SummaryInformation("DocumentSummaryInformation8*CompObjjObjectPoolD5D5  FMicrosoft Word Document MSWordDocWord.Document.89q