| TROOP 46 ACTIVITY PERMIT 2010 |
| BOY SCOUTS OF AMERICA |
| Central NC Council, North Carolina |
| TROOP 46 ACTIVITY PERMIT 2010 |
| Name of Scout |
| Scout Date of Birth |
| Home Address, City, State, Zip |
| Home Phone (include Area Code) |
| Parent Guardian Emergency Contact Information |
| Name of Parent(s) or Guardian(s) (include first names) |
| Father's Business |
| Business/Daytime Phone |
| Mother's Business |
| Business/Daytime Phone |
| Other Phone (2nd home number, cell phone, pager, etc.) |
| Secondary Emergency Contact (if above parents/guardians cannot be reached) |
| Name of Secondary Contact |
| Relationship |
| Address, City, State, Zip |
| Phone (include Area Code) |
| Our son, or ward, is covered by health and accident insurance by contract with the following named insurance |
| 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) Date |
| Signature of father (or guardian) Date |
| STATE OF NORTH CAROLINA, COUNTY OF |
| On this day of , 20__, personally appeared before me the named , |
| to me 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 Commission Expires |