Boy Scout Troop 91
Manchester, NH 03103
Named Trip:……... …………………………Cost:
Location:…………
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Pick Up Time:……
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Parental Consent & Medical Release
In consideration of the benefits to be derived, and in view of the fact that the Boy Scouts of America is an educational organization, membership in which is voluntary, and having full confidence that every precaution will be taken to ensure the safety and well being of my son during this trip, I hereby agree to his participation and waive all claims against the leaders of this activity or trip, and the officers of Troop 91, agents and representatives of the Boy Scouts of America. If I cannot be reached in the case of an emergency, I hereby give my permission to Troop 91 adult advisors in charge to treat, hospitalize, or secure medical treatment for my son,_______________________ on the following trip:
**In the event that parents or guardians cannot be reached during an emergency,
designate the name and phone number of an emergency contact person over the
age of 21.
______________________________ ____________________________
Name Phone #
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Parent Signature Date Phone #
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Boys Date of Birth Current Daily Medication Taken
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Dosage Instructions
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Medical Insurance Coverage Policy Number