My son, ____________________________________ has my permission to attend _ Spectrum Roller Rink _ on _October 15_ with Cub Scout Pack 3765. I understand that they will be leaving from meet at the Spectrum at   6:00 pm   and returning to leave from the spectrum at 8:00 pm .

I understand that my son will be riding with _______________________

I will make sure he does not attend if he is not feeling well and will let you know.  If his physical activity is to be limited in any way, it is noted below (if additional space is need please use the back of this form):

___________________________________________________________________

If you would like your child to participate in this event, please complete, sign and return this consent/indemnity agreement. As parent or legal guardian, you further agree to defend and fully indemnify Pier PTO, the Boy Scouts of America, Pack 3765 and it's leaders and volunteers against any claim, which may result from any personal actions taken by your child. As parent or legal guardian, you further agree to fully indemnify and hold harmless Pier PTO, the Boy Scouts of America, Pack 3765 and it's leaders and volunteers against any claim which took place during the above identified activity if that claim or cause of action is brought by your child or their parent/legal guardian. I hereby consent to participation by my above named child in the event described above.

I certify that I have an understanding of this agreement and the activity described above that my child would be participating in. I further understand that I had the opportunity to fully discuss the above named activity and this agreement with a representative of the Pack to clarify any concerns or questions about the activity that I may have had.

____________________________________ _________________
Parent/Guardian Name                                      Date

____________________________________ _________________
Parent/Guardian Signature                                Phone

EMERGENCY MEDICAL TREATMENT: In the event of an emergency, I hereby give permission to transport my child to a hospital for emergency medical or surgical treatment. I wish to be advised prior to any further treatment by the hospital or doctor. In the event of an emergency, if you are unable to reach me at the above numbers, please
contact:

____________________________________ _________________
Name                                                                 Phone

____________________________________ _________________
Physician’s Name                                               Phone

____________________________________ _________________
Name                                                                 Phone

____________________________________ _________________
Name                                                                 Phone