Please return to the Scout Master before Departure!

I grant permission for my son, _________________________, to participate in all Boy Scout Troop 163 activities during the camping trip scheduled for __________________. I will not hold Troop 163, any of the leaders, or the vehicle drivers responsible for any accidents which occur in conjunction with this outing.

Medical Waiver Form / BSA Troop 163

I authorize the adult-in-charge of Boy Scout Troop 163 to arrange for and grant authorization to appropriate medical authorities for health care as he/she deems necessary for the well-being of my son.

Parent or Guardian signature: _______________________________ Date: __________________

Parent's (Guardian's) full name: ____________________________

Child's full name: _________________________________________ Birth Date: ______________

Paren't (Guardian's) Insurance Carrier: _______________________ Policy Number: __________

Allergies and/or additional medical information: _________________________________________

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