Troop 3034	Girl Scouts USA	2008-2009
Newton, Massachusetts	Annual Permission form Part 1

This form is to be completed at the beginning of each membership year and kept with the troop/group leader's records. Please complete both sides

Girl's name:__________________________________________ Birthdate:_____________

Yes  No ________ Initial	NEIGHBORHOOD WALKING TRIPS AND OVERALL TROOP ACTIVITY PERMISSION My child has permission to attend neighborhood walking trips during which time the troop will leave the meeting place and return at the regular ending time. My child has my permission to participate in all activities of Troop 3034, Girl Scouts of Eastern Massachusetts, Girl Scouts, USA, including those actitivies held outside the regular meeting place. On behalf of myself and my minor child, I release and agree to hold harmless Girl Scouts USA, their representatives, volunteer troop leaders, and parent volunteers, from any and all claims, liability, and expenses arising from my child's use of or participation in the facilities, programs, and activities of the troop.
Yes  No ________ Initial	COUNCIL SURVEYS In order to continually improve our council services, we would like permission to survey your child about her Girl Scout experience. All of the girls’ answers will be confidential. No names will be written on any of the surveys. In the instance of pre and post surveys, girls will be asked to include their initials and date of birth.
Yes  No ________ Initial	VIDEO/PHOTO RELEASE I hereby consent that the videotapes, photographs and/or audio recordings that may include my daughter may be used by Girl Scouts of the U.S.A. and Girl Scouts of Eastern Massachusetts. I consent that my daughter's first name and photograph may be used on the troop's web site.
Yes  No ________ Initial Youth Large Adult Medium Adult Large Adult X-Large	COOKIE PROGRAM My daughter has my permission to participate in the Annual Girl Scout Cookie Program. I agree to accept financial responsibility for all products and money she receives, and will see that she has adult supervision at all times. I understand that monies collected by my daughter belong to her Girl Scout Troop and to Girl Scouts of Eastern Massachusetts. I understand that orders should not be taken before the opening day of the sale because A GIRL SCOUT DOES HER BEST: TO BE HONEST and TO BE FAIR.
________ Initial	RELEASE RESTRICTIONS My child may NOT be released to:_________________________________________ My child may ONLY be released to:_________________________________________
________ Initial	HEALTH HISTORY (**All Information is strictly confidential) Please help us to make this an enjoyable, successful experience for your daughter by listing any additional medical/physical/emotional condition of which the leader should be aware (i.e., chronic condition, disabilities, behavioral problems, medications, separation anxiety, car sickness etc.): Does your child have allergies, please be specific: Date of last tetanus shot, please be specific:
Yes  No ________ Initial	PERMISSION TO SEEK EMERGENCY MEDICAL ATTENTION By signing this form, I (we) hereby authorize Girl Scouts of Eastern Massachusetts and our child's troop leader to consent to any medical care and treatment for (Child's name)_______________________________________ that is recommended by a licensed healthcare provider to whom the Child is presented for treatment. In order to ensure that the Child receives prompt emergency medical care and treatment when necessary, I (we) hereby release any licesnsed health care provider providing medical care to the Child in reliance of this form from liability relating to such provider's acceptance of my (our) substitute care giver's consent.

Troop 3034 Girl Scouts USA 2008-2009 Newton, Massachusetts Annual Permission form Part 2 Girl's name:__________________________________________ Birthdate:______________   Parent/Guardian Name (Please Print)____________________________ Parent/Guardian Signature___________________________   Address_______________________________ City________________________ State_____ Zip________   Telephones: Home__________________ Cell__________________ Work__________________   Email:______________________________________   Second Parent/Guardian Name (Please Print)_____________________________   Address (if different)______________________________ City_______________ State_____ Zip________   Telephones: Home__________________ Cell__________________ Work__________________   Email:_______________________________________   Girl's Email:_______________________________________ Girl's cell phone:_________________   1st Emergency Contact__________________________________ Telephone__________________   2nd Emergency Contact__________________________________ Telephone__________________   Please add any additional comments concerning your child: