Girl Scouts of Central IndianaSpecial Permission Form

Troop _1097 Date November 21, 2009___ Destination _I.U. math and Science Day @ I.U. Bloomington

Arrangements for transportation

Time and place of departure Meet @11:15 Pleasant Grove parking lot

:Time and place of return _Pickup- 5:30 pm at Pleasant Grove parking lot

Type of transportation __Car, van______________________________________

Leaders accompanying the girls

Name Patricia Johnson_____ Cell#_496-3096_

Troop pays 0Girl pays $ 5__Optional spending money _________________

Money due to troop leader by (date) ___________________________________________________________

Each girl will need to Dress for the weather:light jacket, walking shoes

Other equipment and clothing

In case of an emergency

Leader will notify the troop emergency contact person who will immediately notify the parents.

Emergency contact person _Jeff Johnson_____ Phone __889-9275_______

Leaderís signature†† Patricia Johnson________________________


Tear off bottom half and return to troop leader by (date)†† _______




My daughter ______________________ has permission to attend the Girl Scout trip to I.U. math and Science Day

Participate in the described activity, I may be reached at (phone) (________) _______________________________________

If I cannot be reached in the event of an emergency the following person is authorized to act on my

behalf: Name _________________________________ Phone (___) ____________

Relation to participant ______________________________________________________________________Address _____________________________________________City __________________ZIP _____________Additional remarks: Please note if your child has any specific limitations and/or special needs, including medications. Use additional sheet if necessary

Parentís Signature _________________________________Date_________