Name:
Sam Shakusky
Address:
456 Oakdale Ave
Telephone No.
KL5-6702
Emergency Contact:
None
Does the applicant have siblings/relatives that are former or current Khaki Scouts?
None Please list name and rank
Assigned to Khaki Scout Troop No.
55
Official use only. Do not mark boxes
I hereby grant permission to the Khaki Scouts of North America to act in loco parentis with regards to my son. The organization will be held harmless in the event of accident or injury.
Herbert Billingsley Signature of parent or legal guardian