Name of Scout
  
Scout Date of Birth
  
Home Address, City, State, Zip
  
Home Phone (include Area Code)
  
Troop 46 Activity Permit 2010
Boy Scouts of America
Central NC Council, North Carolina
Troop 46 Activity Permit 2010
Parent Guardian Emergency Contact Information
Name of Parent(s) or Guardian(s)
(include first names)
  
Father's Business
  
Father's Business/Daytime Phone
  
Mother's Business
  
Mother's Business/Daytime Phone
  
Other Phone (2nd home number,
cell phone, pager, etc.)
  
Secondary Emergency Contact (if above parents/guardians cannot be reached)
Insurance Company/Group Plan
  
Name of Parent's Employer
  
Policy or Group Number
  
Certificate or ID Number
  
Address, City, State, Zip
  
Phone (include Area Code)
  
The above named Boy Scout is duly registered as a member of Troop 46, Central NC Council, and, except as noted by me/us, has my/our
permission to participate in all activities sponsored, sanctioned, or engaged in by Troop 46 (or any sub-group of Troop 46) and/or approved by
the leaders of Troop 46 for the calendar year 2010. These activities include, but are not limited to, overnight camping trips, backpacking and
hiking expeditions in rugged wilderness and backcountry areas, white-water rafting excursions, canoeing, sailing, swimming, horseback riding,
rock climbing and rappelling, mountain biking, Super Scout high adventure trips, mountain and beach trips, Order of the Arrow functions,
camping at Boy Scout camps and reservations, and all travel to and from, or related to, any of these activities.

Further, if at any time during which my/our son or ward is a participant in any of the activities authorized above and an illness or medical
emergency should arise, I/we understand that every effort will be made to contact me/us. But if at such time the undersigned(s) cannot be
contacted to give advice and consent regarding such illness or medical emergency, then, and in such event, I/we do hereby authorize any of
the leaders in charge of such activity to give advice and consent with regard to the medical care and treatment of my/our son or ward.  Such
advice and consent shall include, but shall not be limited to, the power (i) to provide for such health care at any hospital or other institution, or
the employing of any physician, dentist, nurse, or other person whose services may be needed for such health care, and (ii) to consent to and
authorize any health care, including administration of anesthesia, X-ray examination, medication, performance of operations, and other
procedures deemed advisable by and is to be rendered under the general or specific supervision of, a licensed physician, dentist, and other
medical personnel except the withholding or withdrawal of life sustaining procedures.  In addition to the foregoing, such leader or leaders shall
be authorized to give and administer such emergency first aid as, in the judgment of such leader(s), is necessary and appropriate.

By signing here, I indicate that I have the understanding and capacity to communicate health care decisions and that I am fully informed as
to the contents of this document and understand the full import of this grant of powers to the agents named herein.
Signature of mother (or guardian)                                                               Signature of father (or guardian)

__________________________________                                                ________________________________________________
Date                                                                                                            Date

_________________________                                     ____________________________________
STATE OF NORTH CAROLINA, COUNTY OF ______________

On this day of _________________, 20__, personally appeared before me the named
_______________________ to be known and known to me to be the person described in and who
executed the foregoing instrument, and he (or she) acknowledges that he (or she) executed the same and
being duly sworn by me, made an oath that the statements in the foregoing instrument are true.


_____________________________________________
Notary Public


_____________________________________________
My CommissionExpires
Our son, or ward, is covered by health and accident insurance by contract with the following named insurance
Name of Secondary Contact
  
Relationship
  
Address, City, State, Zip
  
Phone (include Area Code)