Troop 347 Port Republic MD

Boy Scouts of America

BOY SCOUTS OF AMERICA, NATIONAL CAPITAL AREA COUNCIL, WESTERN SHORES DISTRICT
CHARTER ORGANIZATION: Church by the Chesapeake

PERMISSION FORM
Name: Noah Breskes Kings Landing Low Ropes Course Eagle Service Project
Emergency Contact: _____________________________ Phone: _______________________
I give permission for my photograph to be taken and allow BSA and Troop 347 to release said
pictures for publicity and Troop Historian purposes.
In consideration of the benefits to be derived and having full access and confidence that every
precaution will be taken to ensure my safety and well being as a volunteer, I agree not to hold the
BSA liable and expressly waive all claims against Troop 347, National Capital Area council and
Western Shore District, or their representative, or the Calvert Nature Society, Calvert County
Natural Resources, its employees and agents, all sponsors, volunteers, owners of property,
transporters, and other participants and Leaders on account of any accident, injury, illness or any
other damage that may occur in connection with, or incident to this event.
In the event the emergency contact cannot be reached during an emergency, I hereby grant
permission to the adult leader in charge to obtain medical treatment at the nearest hospital or
Doctor.

Participants Signature_____________________________ Date __________________

------------------------------------------------------------------------------------------------------------------------EVENT Point of Contact:

Leader:

Thomas Breske

Cell: 410-610-7450