------------------Print out page one only and return by "due date"----------------------------


In consideration of the benefits to be derived, and in view of the fact that the Boy Scouts of America is an educational institution membership in which is voluntary, and having full confidence that every precaution will be taken to ensure the safety and well being of my Scout/s (son/s or ward/s) namely:

___________________________________________________________ on the
monthly activity, I agree to his participation and waive all claims against the leaders of this trip, officers, agents, and representatives of the Boy Scouts of America and the sponsor. In the event of an emergency, the Troop leader of the activity has my permission to obtain medical treatment for this Scout at the nearest hospital or doctor, at my expense, if our own doctor is not readily available, and as restricted on Troop 172 Health History or the BSA Personal Health and Medical Record on
file with TROOP 172.


Physician's name and phone number

Printed name of parent ______________________________________

Home phone __________________________________________


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