For: Maine Rock Gym
When: April 4th, 2005, 6:00 - 8:00 p.m.

Payment: $16 due with permission slip - MRG Waiver also required.

Scout Name(s): _____________________________________________________________
has permission to participate in all aspects of the above Boy Scout activity with the leaders and parents of BSA Troop 58. I understand the risks and dangers involved, and will not hold the leaders nor Troop 58 liable for any accident or injury which may occur during this activity. In the event of illness or accident in the course of this activity, I request that measures be instituted without delay as the judgment of Troop leaders or medical personnel dictates.

Emergency phone: _________________________________________________________________________

Signed: ______________________________________ Date ___________________


_________________________________________________________________________
(Please print - name of parent or guardian)