Jun 18, 2019 | Global Documents |
Rev. 1/2016-‐1 www.girlscoutsLA.org 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 qName of Indoor Overnight Trained adult attending: ________________________________Training Date: _____________ q N/A qName of Camping Skills Trained adult attending: __________________________________ Training Date: _____________ q N/A qName of Domestic Travel Trained adult attending: _________________________________Training Date: _____________ q N/A qName of International Travel Trained adult attending: ______________________________Training Date: _____________ q N/A qName of Private Certified Lifeguard: ______________________ Certificate Exp.: ________ q Using Lifeguard(s) on site q N/A qName of Other Certified Specialist: _______________________ Certificate Exp.: ________ q Using Specialist(s) on site Type of other Specialist: q N/A qA contract agreement is needed and required by site for this activity and has been submitted to email@example.com q N/A qNon-‐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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