Part A: Informed Consent, Release Agreement, and Authorization
Full name: ___________________________________________
Date of birth: _________________________________________
A
High-adventure base participants:
Expedition/crew No.: _______________________________________________
or staff position: ___________________________________________________
680-001
2019 Printing
Adults NOT Authorized to Take Youth to and From Events:
Informed Consent, Release Agreement, and Authorization
I understand that participation in Scouting activities involves the risk of personal injury, including
death, due to the physical, mental, and emotional challenges in the activities offered. Information
about those activities may be obtained from the venue, activity coordinators, or your local council.
I also understand that participation in these activities is entirely voluntary and requires participants
to follow instructions and abide by all applicable rules and the standards of conduct.
In case of an emergency involving me or my child, I understand that efforts will be made to
contact the individual listed as the emergency contact person by the medical provider and/or
adult leader. In the event that this person cannot be reached, permission is hereby given to the
medical provider selected by the adult leader in charge to secure proper treatment, including
hospitalization, anesthesia, surgery, or injections of medication for me or my child. Medical
providers are authorized to disclose protected health information to the adult in charge, camp
medical staff, camp management, and/or any physician or health-care provider involved in
providing medical care to the participant. Protected Health Information/Condential Health
Information (PHI/CHI) under the Standards for Privacy of Individually Identiable Health Information,
45 C.F.R. §§160.103, 164.501, etc. seq., as amended from time to time, includes examination
ndings, test results, and treatment provided for purposes of medical evaluation of the participant,
follow-up and communication with the participant’s parents or guardian, and/or determination of
the participant’s ability to continue in the program activities.
(If applicable) I have carefully considered the risk involved and hereby give my informed consent
for my child to participate in all activities offered in the program. I further authorize the sharing
of the information on this form with any BSA volunteers or professionals who need to know of
medical conditions that may require special consideration in conducting Scouting activities.
With appreciation of the dangers and risks associated with programs and activities, on my
own behalf and/or on behalf of my child, I hereby fully and completely release and waive
any and all claims for personal injury, death, or loss that may arise against the Boy Scouts
of America, the local council, the activity coordinators, and all employees, volunteers,
related parties, or other organizations associated with any program or activity.
I also hereby assign and grant to the local council and the Boy Scouts of America, as well as their
authorized representatives, the right and permission to use and publish the photographs/lm/
videotapes/electronic representations and/or sound recordings made of me or my child at all
Scouting activities, and I hereby release the Boy Scouts of America, the local council, the activity
coordinators, and all employees, volunteers, related parties, or other organizations associated
with the activity from any and all liability from such use and publication. I further authorize the
reproduction, sale, copyright, exhibit, broadcast, electronic storage, and/or distribution of said
photographs/lm/videotapes/electronic representations and/or sound recordings without limitation
at the discretion of the BSA, and I specically waive any right to any compensation I may have for
any of the foregoing.
Every person who furnishes any BB device to any minor, without the express or implied permission
of the parent or legal guardian of the minor, is guilty of a misdemeanor. (California Penal Code
Section 19915[a]) My signature below on this form indicates my permission.
I give permission for my child to use a BB device. (Note: Not all events will include BB devices.)
Checking this box indicates you DO NOT want your child to use a BB device.
List participant restrictions, if any: None
________________________________________________________
Complete this section for youth participants only:
Adults Authorized to Take Youth to and From Events:
You must designate at least one adult. Please include a phone number.
Name: _________________________________________________________________
Phone: _________________________________________________________________
Name: _________________________________________________________________
Phone: _________________________________________________________________
Name: _________________________________________________________________
Phone: _________________________________________________________________
Name: _________________________________________________________________
Phone: _________________________________________________________________
I understand that, if any information I/we have provided is found to be inaccurate, it may limit and/or eliminate the opportunity for participation in any event or activity. If I am participating at
Philmont Scout Ranch, Philmont Training Center, Northern Tier, Sea Base, or the Summit Bechtel Reserve, I have also read and understand the supplemental risk advisories, including height
and weight requirements and restrictions, and understand that the participant will not be allowed to participate in applicable high-adventure programs if those requirements are not
met. The participant has permission to engage in all high-adventure activities described, except as specically noted by me or the health-care provider. If the participant is under the age of 18, a
parent or guardian’s signature is required.
Participant’s signature: ____________________________________________________________________________________________ Date: ______________________________
Parent/guardian signature for youth: __________________________________________________________________________________ Date: ______________________________
(If participant is under the age of 18)
NOTE: Due to the nature of programs and activities, the Boy Scouts of
America and local councils cannot continually monitor compliance of program
participants or any limitations imposed upon them by parents or medical
providers. However, so that leaders can be as familiar as possible with any
limitations, list any restrictions imposed on a child participant in connection with
programs or activities below.
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