PARENT PERMISSION FORM
For a Troop/Group activity away from the usual meeting place (field trips, hikes, camping, etc.)
Girl Scouts of Moingona Council: 10715 Hickman Road, Des Moines, IA 50322
Phone: 515-278-2881 or 800-342-8389, Fax: 515-278-5988, mgsc1@aol.com
Ames-Gilbert Girl Scout Service Unit: http://girlscouts.amesweb.com/

Troop #: _________ is planning a _________________________ to __________________________ date: ________

Transportation
o	Time and place of departure: ________________________________________________________________
o	Time and place of return:____________________________________________________________________
o	Mode of transportation: __________________________________________

Requirements:
o	The cost per girl will be _______________ for ___________________________________________________
o	Each girl will need (list of necessary equipment/clothes):

Supervision:
o	The leaders in charge will be _______________________________ and _______________________________
o	In case of emergency, the leaders should notify (name & phone#):______________________________________

Leader signature: ______________________________ and phone number ___________________________

”Girl Scouts of Moingona Council are committed to the education, acceptance, and appreciation 
of its diverse membership and assures that all have equal opportunities in the Girl Scout Program”
Return bottom portion only to Troop/Group Leader
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My daughter ___________________________ has permission to participate in __________________________________
on ________________________. I understand that the cost will be ______________________

She is in good physical condition and has not had any serious illness or operation since her last health exam. I shall make sure that she does not attend if she is not feeling will and will also inform you should that be the case.

Please provide any information about disabilities, medication, and/or special health situations:

During the activity, I can be reached at _____________________________________, phone: ____________________

Physician’s name & phone number: ___________________________________________________________________

Where immediate care is necessary the leader in charge, _____________________________________ has permission to seek medical attention.

Date: ___________________  Signature: ________________________________________________________
					  (Parent or Guardian)