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Local Permit No. ___________ Date Issued ________________
This application must be filled with local council service center 2 weeks in advance of scheduled activity for proper clearance. It is used for trips of less than 500 miles. If destination is 500 miles or more one way or outside the U.S.A. (local council camp excepted), use National Tour permit Application, No. 34419. if backcountry trip, be sure to know BSA Wilderness Use Policy.

Unit________ No. ____________ Town __________________ District ______________________ hereby applies for a permit and submits plans herewith for a trip from ____/____/____ to ____/____/____.

Give itinerary if tour; or destination if camp, including route description for reaching campsite (for long trip attach map indicating route and overnight stops):
____________________________________________________________________________________________________
____________________________________________________________________________________________________

Type of trip: [ ] One Day, [ ] Touring Camp, [ ] Short-term camp, [ ] Long-term camp (Furnish copy of program and menus,)
[ ] Where swimming or boating is included in the progra, Safe Swim Defense, No. 34370, and/or Safety Afloat, No. 34368, standards are to be followed.
Person in charge: _________________________________ [ ] Safe Swim Defense Certification _________________
Expiration: _____________ and/or Safety Alfoat Certification _______________________ Expiration: _____________
or use of adult assistants so qualified: [ ] Safe Swim Defense Certification __________________ Expiration: ___________
and/or Safety Afloat certification ______________________________________ Expiration: ______________
Also, at least one adult must be certified in CPR for Safety Afloat Certification _________________________ CPR Certificate Expiration: __________________

Mode of transportation: [ ] Car [ ] RV [ ] Van [ ] Bus [ ] Boat [ ] Canoe [ ] Train [ ] Hiking [ ] Truck [ ] Other ____________
(The beds of trucks and camper trucks are approved for equipment only--passengers are allowed only in cab.)

Tour will include ___________ youth and __________ adults. Have parent's approvals been secured? ___________________
It is the tour leader's and unit committee member's understanding that all drivers, vehicles, and insurance coverage will meet the national requirements listed on the reverse side of this application. The Boy Scouts of America policy requires two adult leaders on all camping trips and tours. Tour leader in charge must be at least 21 years of age.

Tour leader's name (print or type) ___________________________________ Age _______ Phone _____________________
Address _____________________________________________________________________________________

Assistant tour leader's name _______________________________________ Age _______ Phone _____________________
Address _____________________________________________________________________________________

_________________________________ Signed by member of unit committee

________________________________ Signed by tour leader