02/11/99
				Troop 165
			Activity Permission Slip

Event Description: Uwharrie Hiking Trip (5 Miler)
Destination: Uwharrie State Park
	Emergency Contact:

Departure Date: February 20, 1999	Departure Time: 7:00am
(Depart from the Scout Hut)
Return Date: February 21, 1999		Return Time: 12:00pm
(Pick up at the Scout Hut)
Event fees, payable in cash only, are due the Monday before departure:
  Fee: 2 Meal(s) @ $3.00 plus $0.00 = $6.00
		Retain Upper Portion for Your Information
			Fold and Tear on Dotted Line
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Scout's Name:________________________

Parent/Guardian:_________________________

Address:________________________________________________________________________
	________________________________________________________________________

Alternate Contact: 	Name:___________________________
			Address:________________________________________________
				________________________________________________
			Phone: (H)______________ (W)_____________
********************************************************************************
Current Health/Medical Statement

Preferred Physician:____________________________________________________________
	Phone: (Office)_______________ (Pager)________________
Current Medication: (Give to adult in charge)
	Type of Medication:___________________________________
	Directions for Use:_____________________________________________________
			   _____________________________________________________
Parental/Medical Restrictions: (Describe in detail)_____________________________
________________________________________________________________________________
________________________________________________________________________________

Participation Authorization and Medical Treatment Consent

In consideration of the benefits to be derived, and in view of the fact that the
Boy Scouts of America is an educational organization, membership in which is
voluntary, and having full confidence that every precaution will be taken to
ensure the safety and well-being of my son during this activity. I agree to his
participation in this activity. In the event of an emergency, where I cannot be
reached, I hereby give permission to the adult leader in charge to take
necessary steps for medical/emergency treatment in accordance with Boy Scouts of
America policy. All information filled on the scout application as to physical
and medical conditions are current.
The person named herein has my permission to engage in above activity except as
noted under parental/medical restrictions.

Signature:________________________________________ Date:___/___/___