PERMISSION, RELEASE AND INDEMNITY AGREEMENT FOR 2006-2007

TO THE SCOUTMASTER & LEADERS OF TROOP 55, BOY SCOUTS OF AMERICA:

THIS PERMISSION, RELEASE AND INDEMNITY AGREEMENT HEREBY PROVIDES YOU THE FOLLOWING, TO WIT:

1. AS PARENT OR LEGAL GUARDIAN OF THE CHILD LISTED BELOW, YOU HAVE MY PERMISSION AND CONSENT FOR MY SON, OR WARD, TO ACCOMPANY TROOP 55 ON BOY SCOUT ACTIVITIES DURING THE YEAR 2006.

2. I RECOGNIZE AND ACKNOWLEDGE THAT ACCIDENTS AND INJURIES CAN AND SOMETIMES DO OCCUR DURING SCOUTING ACTIVITIES AND TRIPS. I HEREBY INDEMNIFY, RELEASE AND HOLD HARMLESS THE SCOUTMASTER, TROOP 55 AND ITS LEADERS, DESIGNEES AND ASSIGNEES IN THE EVENT OF ANY ACCIDENT OR INJURY TO MY SON OR WARD.

3. THE SCOUTMASTER, ANY OF TROOP 55’S ADULT LEADERS, OR THEIR DESIGNEES AND ASSIGNEES, MAY IN THE EVENT OF A MEDICAL EMERGENCY, ADMINISTER FIRST AID AND/OR SEEK AND PROCURE MEDICAL TREATMENT AS DEEMED NEEDED AND APPROPRIATE FOR MY SON OR WARD. THIS MAY INCLUDE, BUT IS NOT LIMITED TO: INJECTIONS, ANESTHESIA, SURGERY, OR TREATMENT AS PRESCRIBED OR RECOMMENDED BY THE AVAILABLE MEDICAL PERSONNEL. I AGREE THAT I OR MY INSURANCE WILL BE RESPONSIBLE FOR THE COST OF ALL SUCH TREATMENT. I HEREBY INDEMNIFY, RELEASE AND HOLD HARMLESS THE SCOUTMASTER, TROOP 55 LEADERS, THEIR DESIGNEES AND ASSIGNEES, AND TROOP 55 WITH RESPECT TO THEIR SEEKING AND PROCURING ANY MEDICAL ATTENTION AND TREATMENT FOR MY SON OR WARD.

4. BY SIGNING THIS FORM, I AFFIRM THAT I HAVE READ, APPROVE AND CONSENT TO THE FOREGOING PERMISSION, RELEASE AND INDEMNITY PROVISIONS OF THIS DOCUMENT.

Scout’s Name: _______________________________________________________________

Health Care Provider (Name of Insurance Co.):______________________________________

Physician’s Name: ________________________ Physician’s #:________________________

Allergies or Medical Conditions: ________________________________________________

Parent’s Names:

Father: _________________________ Home # ______________ Cell # ______________

Mother: ________________________ Home # ______________ Cell #______________

Emergency Contact Name: ______________________ Emergency Contact #: _____________

Parent’s Signature: ___________________________________ Date: __________________

Please return this form to James McLaren - phone (901) 524-4947