Permission Slip

PEOPLE IN CHARGE: John McCarthy, Joe Walsh

ACTIVITY: Bertha Brock 2005

TIME AND DATES: Friday-Sunday, January 14-16, 2005

WHERE: Bertha Brock County Park

PHONE: (emergency only!) (517) 699-8179; the phone number for the Bertha Brock ranger is 616-527-0478; the phone number for the park is 616-527-0703

MEET AT: Olivet Baptist Church, Friday, January 14, 5:00 p.m.

PICK UP: approximately 1:00 p.m. on Sunday, January 16, at Olivet Baptist Church

ON THIS OUTING WE WILL BE: sledding and skating (as conditions allow)

COSTS: $25.00 for lodging, firewood, and meals

SPECIAL INSTRUCTIONS: Wear your Boy Scout shirt, if you have one. Dress according to the weather.

EACH PERSON WILL BE RESPONSIBLE FOR BRINGING THEIR OWN PERSONAL GEAR AND FOR TAKING CARE OF IT PROPERLY.

THIS PERMISSION SLIP AND THE TOTAL FEE OF $25.00 IS DUE BY: Tuesday, January 11, 2005

" -------Cut--------keep top portion---------return bottom portion--------cut---------- "

I GIVE PERMISSION FOR MY SON TO JOIN TROOP 272 ON THE FOLLOWING ACTIVITY: ___________________________________________

ON THIS DATE: ____________________________________________________

SIGNATURE OF PARENT OR GUARDIAN: ____________________________

I, ________________________________________________ (print scout’s name)

PROMISE TO OBEY THE SCOUT OATH, LAW AND OUTDOOR CODE.

SCOUT'S SIGNATURE: ____________________________________________

IN AN EMERGENCY, (name) _______________________________________

CAN BE REACHED AT THIS PHONE NUMBER ______________________

In case of Emergency, I understand every effort will be made to contact me (if an adult, my spouse or next of kin). In the event I cannot be reached, I hereby give my permission to the physician selected by the adult leader in charge to secure proper treatment, including hospitalization, anesthesia, surgery, or injections of medication for my child (or for me, if an adult).