PERMISSION SLIP
PERMISSION SLIP

Please print this permission slip, fill it out, have your spouse, parent or significant other (hereafter referred to as Responsible Adult) sign it and bring it to the event. While you are filling this out, ask yourself if you really want to go on an adventure with people who have a website named Evil Scoutmaster. If we do not have a signed permission slip on file, you will not be permitted to participate in the event.

Activity: _________________________________________________________________
From (date/time): ___/___/___, _______ To (date/time): ___/___/___, _______

Name: ___________________________________ Date of Birth:___/___/___ Age:__ Gender:___
Doctor's Name: ________________ Phone : (___)_______ Insurance Name: ____________ Policy # : ____________

Circle Yes for all items that apply, past or present, to your health history and explain them in the comments block below.
Yes    No - Asthma Yes    No - ADHD (Attention-Deficit Hyperactivity Disorder)
Yes    No - Hemophilia Yes    No - Diabetes
Yes    No - High blood pressure Yes    No - Heart trouble

Comments:

List any allergies, especially food, medicines, insects, plants (if none, please enter None.)

List ALL medications taken in the 30 days prior to arrival and any medications to be taken during the activity (if none, please enter None.)

List any physical or behavioral conditions that may affect or limit full participation in strenuous activities that will undoubtedly involve being cold, wet, muddy and/or bleeding (if none, please enter None.)

Give Month/Year of last Tetanus toxoid: __/__

As the Responsible Adult of the above person, I give permission for:
 1. the individual listed to fully participate in the activity listed above, subject to limitations noted above.
2. the individual listed to be transported by a volunteer driver with limited skills and abilities in a vehicle of questionable mechanical reliability on paved roads, unpaved roads, icy roads, flooded roads, the side of the road and/or off road.
3. the first aid person to practice first aid (and we mean practice - they might not be very good at it yet), administer medications and liquor as needed.
4. in case of emergency, I understand every effort will be made to contact me. In the event I cannot be reached, I hereby give my permission for the trip leader to secure proper treatment, including hospitalization, exorcism, anesthesia, leeching, surgery, or injections of medication for the individual listed.
5. the individual listed to be photographed and/or video taped during the event, and for the images and/or recordings to be published, reproduced, or distributed in all outlets, including, but not limited to, television, newspapers, internet, recruitment materials, and ads without liability or limitation on my or their part.

Name of Responsible Person: (Please print clearly)____________________________ Phone: (___)_______
Address: ______________________________ City:______________ Zip:_________Cell Phone: (___)_______
If person named above is not available in the event of an emergency, notify:
#1 Name : _____________________ Relationship : ____________________ Phone : (___)_______
#2 Name : _____________________ Relationship : ____________________ Phone : (___)_______

If the activity ends early or nobody comes to pick up the attendee and I cannot be reached, please deliver the attendee to:
Name: _______________ Phone : (___)_______ Address: ______________________ City:___________

If the participant dies during the activity and their body can be recovered, please deliver the corpse to:
Name: _______________ Phone : (___)_______ Address: ______________________ City:___________

Signature of parent/guardian or adult Signature:_____________________________ Date:___/___/___
Signature of participant:_____________________________ Date:___/___/___