W. D. Boyce Council                 Boy Scouts of America

For Boy Scout Troop 21


I hereby grant permission for _____________________________ to go
to ______________________________________,
on (enter dates) _______________________,
under the leadership of Mark Gauf; and in consideration of his engaging in this activity, I agree
to hold harmless the said leaders and their associates; our unit's sponsoring institution and the
Boy Scouts of America because of any claim arising on behalf of my said son from a possible injury
or illness while engaged in this activity.  

    ( ) Parent will attend        
    ( ) Parent will not attend

I may be reached at (phone)________________,
(address)________________________(city)_________________________ during this time.  In the event I
cannot be reached and emergency medical treatment is required,
(check one)

( ) you may contact

    (name) _____________________________
    (phone) ___________________
    for authorization, or

( ) you may authorize medical authorities to prescribe such
     treatment.

Date _________    
Signed (Parent or Guardian)________________________________