PERMISSION FORM – Girl Scout Western Pennsylvania
Activity:
Date and time of activity:
Location of activity:
Time and place of departure:
Time and place of return:
Mode of transportation:
Driver’s name(s):
Items needed for activity:
Parents return the bottom portion of this form to the troop leader by
Activity Date:
My daughter,
, is able to attend, and I hereby give my
permission for her to participate.
My daughter,
, is unable to attend.
To the best of my knowledge, my daughter is in good health and free of illness at this time.
I give permission for her to be photographed for print, digital or electronic images. These images
may be used by the troop or GSWPA in news releases or other published formats.
I wish to opt out of the above media permission.
Please list any serious health problems or allergies that may affect your daughter during this
activity:
During this activity, I can be reached at home or by cell at these numbers:
Phone-home
Phone-cell
If I cannot be reached in the event of an emergency, the following person is authorized to act on my
behalf. Please make sure this person is aware of the date and time of the activity.
Name:
Relation to Girl Scout:
Phone:
Who will pick up your daughter after the activity (name and relation):
Name
Relation
Parent/Guardian Signature
Date
Please update your daughters health history form if anything has changed.
If you have special instructions or comments, please use the reverse side.
189