Cub Scout Pack 78 / Boy Scout Troop 78

Scout's Name____________________  Activity Date(s)_________-_________

Activity _______________________  at_________________________________

1. My child has permission to participate in the above activity.

   Yes________        No________

2. I am willing for them to take part in the full program including
   swimming and boating, if offered.

   Yes________        No________

3. I have submitted my child's health record to the leader.
   Yes________        No________

I hereby waive and release the Boy Scouts of America and all
individuals, staff members or volunteers working in connection
with Boy Scout activities from any and all possible claims for
injury to person or property which might arise in connection
with my child's participation in activities sponsored or provided
by you.
I do not hold the Council responsible for any accident or illness
which might occur and authorize the adult in charge, should it be
necessary, to secure the service of a doctor at my expense.
(Parent will be notified in case of an emergency.)

Parent/Guardian Signature____________________Phone #(H)______________

Address______________________________________Phone #(B)______________

City_________________________________________State____Zip____________

Emergency contact who can be reached by telephone if parent is
unavailable for any reason:

Name______________________Phone #(H)_______________(B)_______________

Form version date - 4/20/2002