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TROOP 51 PERMISSION SLIP
Event: C&O Canal West end
Date: Saturday June 20- Monday June 22, 2015
Departing Cornerstone at 5 AM and return approx. 6 PM.
COST – $ 40
This trip is limited to 1st class scouts and above. Mountain bike recommended.
Slips and payment due back by June 9, 2015
--------------------------------------CUT HERE AND RETURN BOTTOM------------------------------------------------------------------------------------I give _______________________ (participant) permission to participate with Troop 51 in
the C&O Canal West End trip. If in the judgment of the responsible adults present,
participant requires medical care, I also give permission for such care to be given as
deemed appropriate.
Signature of parent/guardian: ________________________________________________________
Name (please print): _________________________________________________________________
Phone number: ______________________________________________________________________
Alternate emergency contact: ________________________________________________________
Alternate phone number: _____________________________________________________________
Insurance Information:
Participant may take:
 Tylenol  Ibuprofen  Aspirin  Peppermint Benadryl
Insurance Carrier ____________________________
Group Number ______________________________
PAID □
CASH □ CHECK # __________
Please list all medications being taken (Must come in original container)
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