November 2009 Permission Slip

VENTURING CREW 1420 PERMISSION SLIP for Putt Putt Fun Center

Destination:

Putt Putt Fun Center & Starbucks – Constant Friendship Blvd., Abingdon, MD

Date/Time:

Saturday November 14th - 6:30-9:30 PM (includes travel time)

Meet/Depart:

All Venturers should get dropped off and picked up at the JVFC parking lot.

Cost:

$10 – Checks payable to Venturing Crew 1420

What to Bring: Equipment provided by the facility Tour Leader:

Mimi Hatch, home (410) 557-6566 or (410) 977-7874 (cell)

I give permission for ___________________________________________________ to participate in the trip or activity described above to be sponsored by Venturing Crew 1420. In consideration of the benefits to be derived from participation in this crew trip or activity, any and all claims against the Boy Scouts of America or its local councils, Venturing crew, and chartered organization, or against the officers, employees agents, or other representatives of any of them, or any other persons working under the direction or engaged in the conduct of their affairs, arising out of any accident, illness, injury, damage or other loss or harm to/or incurred or suffered by the applicant named above or to his or her property, in connection with or incidental to the crew trip or activity, including preliminary training and travel, are hereby expressly waived by the applicant and the applicant’s family or guardians. In the event of illness or injury occurring to my son or daughter while involved in this crew trip or activity, I consent to X-ray examination, anesthesia, and/or medical or surgical diagnostic procedures or treatment considered necessary in the best judgment of the attending physician and performed by or under the supervision of a member of the medical staff of the hospital or treatment center furnishing medical services. It is understood that in the event of a serious illness of injury, reasonable efforts to reach me will be attempted. I hereby approve and agree to all the terms and conditions of this application and certify its correctness. Further, I certify that this Venturer can meet the health and physical fitness requirements of the crew trip or activity.

Insurance company: _______________________________________ Policy #:__________________________ Personal physician: _____________________________________ Tel #: ______________________________ Allergies: [ ] Food [ ] Medication [ ] Environment

Please describe: ______________________________

Prescription or non-prescription medication currently being taken: ____________________________________ Special instructions/explanations: ______________________________________________________________ Emergency Contact/Phone Number: ___________________________________________________________ CREW POLICY PROHIBITS the use of tobacco, alcohol, and illegal drugs by Venturers or adult leaders during all activities.

_______________________________________________ ________________________________________ Venturer Signature/Date Parent/Guardian Signature/Date TEAR HERE – KEEP LOWER HALF

VENTURING CREW 1420: Putt Putt Fun Center & Starbucks – Constant Friendship Blvd., Abingdon, MD Destination:

Putt Putt Fun Center

Meet/Depart:

All Venturers should get dropped off and picked up at the JVFC parking lot.

Cost:

Date/Time: November 14th, 2009 - 6:30-9:30 PM

$10

Tour Leader:

Mimi Hatch, home (410) 557-6566, cell (410) 977-7874