Girl Scout Parent Permission Form

Jun 18, 2019 | Publisher: Global Documents | Category: Forms |  | Collection: Legal Forms | Views: 6 | Likes: 1

Rev. 1/2016-­‐1   EMERGENCY:  (877)  423-­‐4752   GSGLA  PARENT/CAREGIVER  PERMISSION  FORM This  form  is  REQUIRED  for  EVERY  activity  or  trip,     for  EACH  girl,  whether  parents/caregivers  attend  or  not.   1. Please  refer  to  What  I  Need  For  My  Girls  to  Attend  A…  for  more  information 2. For  Extended  Overnights  (3+  nights)  or  High  Risk  Activities  –  Also  fill  out  the  Extended  Travel  and/or  High  Risk  Application  for GSGLA  approval TOP  portion  is  for  parent/caregiver  information  to  keep.  BOTTOM  portion  to  be  returned  signed  to  Leader.   q    Regular  Troop/Group  Meetings  (One  form  yearly,  list  or  attach  dates)  –  for  meetings  at  the  regular  day  and  time  but  at  a   different  location,  only  advance  written  notification  to  parents/caregivers  is  required.       q    Day  Trips  –  other  than  regular  meeting  day  or  time,  send  Permission  Form  to  SUM/Designee  at  least  2  weeks  prior.   q   Short  Overnight  Trips  –  (1-­‐2  nights)  SUM/Designee  approval  required  prior  to  sending  Permission  Form  to  parents   q   High  Risk  –  (See  Safety  Activity  Checkpoints)  SUM,  Go-­‐Team,  GSGLA  approval  required   q   Extended  Overnight  Trips  –  (3+  nights)  SUM,  Go-­‐Team,  GSGLA  approval  required     q    Product  Sale  Boothing  (One  form  yearly,  list  or  attach  dates)       Activity  Information   Date:  _____________________        Activity  Description:  _______________________________________________________________   Destination  Address:    _________________________________________  City:    _________________      State:    _____        Zip:    _________   Transportation  to  Destination:      q  Walk      q  Parent/Caregiver  Private  Vehicle      q  Troop  Carpooling    q  Other  _________________   Drop  Off  Location:    _______________________  Time:    __________  Pick  up  Location:    ______________________  Time:    __________   Troop/Group  Pays:    __________      Family  Pays:    __________      Purpose  of  Fee:  _____________________________________________   Please  Bring:  _________________________________________________________________________________________________   Troop  Information  Required   Troop/Group  #:    __________            Level(s):    q  D      q  B      q  J      q  C      q  S      q  A          Service  Unit:    _________________________________   Leader/Adult  in  charge:  ___________________________________________________________   Phone:  ______________________   Second  Leader/Adult  in  charge:  _____________________________________________________  Phone:  ______________________   Off  Site  Emergency  Contact  Person:  __________________________________________________  Phone:  ______________________   Name  of  First  Aider:  ________________________________________________  Certification  Expiration  Date:  ___________________    (Valid  certification  in  First  Aid/CPR/AED  trained  Adult  attending)   Special  Training  or  Certification  needed  for  this  activity   q  N/A     qName  of  Indoor  Overnight  Trained  adult  attending:  ________________________________Training  Date:  _____________   q  N/A     qName  of  Camping  Skills  Trained  adult  attending:  __________________________________  Training  Date:  _____________   q  N/A     qName  of  Domestic  Travel  Trained  adult  attending:  _________________________________Training  Date:  _____________   q  N/A     qName  of  International  Travel  Trained  adult  attending:  ______________________________Training  Date:  _____________   q  N/A     qName  of  Private  Certified  Lifeguard:    ______________________  Certificate  Exp.:    ________      q  Using  Lifeguard(s)  on  site     q  N/A     qName  of  Other  Certified  Specialist:    _______________________  Certificate  Exp.:    ________      q  Using  Specialist(s)  on  site   Type  of  other  Specialist:       q  N/A     qA  contract  agreement  is  needed  and  required  by  site  for  this  activity  and  has  been  submitted  to   q  N/A     qNon-­‐member  Insurance  obtained   q  I  have  reviewed  Girl  Scout  procedures  for  this  activity  and  agree  to  comply  with  GSGLA  Volunteer  Essentials  and   Safety  Activity  Checkpoints,  and  have  completed  required  training/online  modules.     Leader  or  Adult  signature  in  charge  during  activity:  _______________________________________Date:  ___________   Overnight  Approval  for  this  activity    SUM/Designee  signature_________________________________________ Date:  ___________   "          "          "          "          "          "          "          "          "          "          "          "          "          "          "          "          "          "          "          "          "          "   Parent/Caregiver,  please  complete,  sign  and  return  only  this  bottom  portion  to  Leader   Activity  Description  _____________________________________________________________          Date:  _______________________   My  daughter_________________  has  my  permission  to  participate  with  this  troop/group  in  the  above  activity  on  this  date  and  time.   During  the  activity,  I  can  be  reached  by  phone  at:  _______________________________________________________________   If  I  cannot  be  reached  contact:  _____________________________________________________Phone  ________________________   q  My  daughter  cannot  participate  in:    ____________________________________________________________________________   q  My  daughter  is  in  good  health.  If  she  has  a  known  complicating  medical  problem  or  has  had  an  operation,  serious  illness,  or   convulsive  disorder  since  her  last  health  examination,  I  understand  that  written  permission  from  a  doctor  must  accompany  this  form   for  my  daughter  to  participate  in  water  sports,  horseback  riding,  skiing,  hiking,  sports,  and  other  physically  demanding  activities.   q  I  have  discussed  appropriate  behavior  with  my  daughter.  Also,  I  will  make  sure  she  does  not  participate  if  not  feeling  well.   Parent/Caregiver  Signature:  ________________________________________________________ Date:  ______________

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