Boy Scouts of the Philippines

LUPON, DAVAO ORIENTAL

Title of Activity : ________________________________________________

Date : ________________________________________________
Venue : ________________________________________________

PARTICIPANT’S INFORMATION SHEET

Name: Age:
Surname Given Name Middle Name
Birthday: Birthplace:
Father’s Name: Occupation:
Mother’s Name: Occupation:
Complete Home
Address:
Person to contact in case of Emergency:
Name: Relationship:
His/Her Address: Contact #:
SponsoringInstitution/School: Grade & Section:

Langkay/Kawan/Troop #: Date Unit Reg. Expires:

__________________________________________________________________

PARENT’S CONSENT
Date: _______________________

This is to certify that I/we permit our child, Scout __________________________________________

to participate in the ______________________________________________________ __ to be held on

_____________________at ________________________________________________________________.

I/We expressly waive any and all claims against the school and or its representative on the account of any
incident/injury or damage to personal property that may occur beyond the control of the delegation head provided
that adequate safety measures and precautions have been instituted in connection with the participation of our
child in the above-mentioned activity. I/We, further, agree that the said Scout-participant undergo health
examination required.

__________________________________________ __________________________________________
Signature of Father/Guardian over Printed Name Signature of Mother/Guardian over Printed Name
__________________________________________________________________

MEDICAL CERTIFICATE
Date: _______________________

This is to certify that I examined Scout __________________________________________, grade ________

pupil of ____________________________________________________________________________ and found him
__________________________________________________ to join the above-mentioned activity.

_______________________________M.D.
License #: _______________________