Boy Scouts of America, Troop 52

201 South King Street

Danbury, CT 06811


Dear Parent or Guardian

This form is required for all Troop 52 trips. No boy may go on a trip without providing this form prior to travel. The Assistant Scoutmasters and I will do everything in our power to protect your son. Two adults will be present at all activities. At least one trained adult will be present on all trips


Bob Glavik

Scoutmaster, Troop 52

I hereby give permission for my son to be transported, including travel outside the State of Connecticut, by the Scoutmaster, or his designee, from Danbury, CT to:

Trip destination:___________________________________________________

Permission is valid for (trip dates): ____________________________________

Scout's Name:  ___________________________________________________

Address:  _______________________________________________________

City, State, Zip:  __________________________________________________

Home Phone #:  __________________________________________________                Emergency Phone #:  ____________________________________________

In consideration of the benefits to be derived, and in view of the fact that Boy Scouts of America is an educational institution, membership in which is voluntary, and having full confidence that every precaution will be taken to ensure the safety of my son on this activity, I hereby agree to his participation and waive all claims against the leaders of this trip and officers, agents and representatives of Boy Scouts of America.


Check any and all that apply:

____  Allergy to a medicine, food, plant, animal, insect or toxin

____  Any conditions that may require special care, medication or diet

____  ADD/ADHD

____  Asthma   ____  Convulsions   ____ Heart Trouble   ____Contact Lenses  ____  Diabetes

____  Fainting Spells   _____  Bleeding Disorders

Limitations of physical activity:  ____________________________________________________________________________


In case of  accident, injury or illness while participating in Troop activities, I hereby give my permission  to the doctor selected by the adult leader in charge to secure proper treatment, including hospitalization, anesthesia, surgery or injections of medications.  .

Signature of Parent or Guardian__________________________________________________          Date:  _______________________

Print Name:  ________________________________________________________________            Relationship:  ________________

Revised 7/11/2005