Part A: Informed Consent, Release Agreement, and Authorization

Full name: ___________________________________________

Date of birth: _________________________________________

A

High-adventure base participants:

Expedition/crew No.: _______________________________________________

or staff position: ___________________________________________________

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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/Condential Health

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/

at the discretion of the BSA, and I specically 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

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

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)

Part B1: General Information/Health History

Full name: ___________________________________________

Date of birth: _________________________________________

B1

High-adventure base participants:

Expedition/crew No.: _______________________________________________

or staff position: ___________________________________________________

Address: _________________________________________________________________ Home phone: _________________________ Other phone: _________________________

Alternate contact name: _________________________________________________________________ Alternate’s phone: ______________________________________________

Age: ____________________________ Gender: __________________________ Height (inches): ___________________________ Weight (lbs.): ____________________________

Address: _________________________________________________________________________________________________________________________________________

City: ___________________________________________State: ____________________________ ZIP code: __________________ Phone: ______________________________

Unit leader: ____________________________________________________________________________ Unit leader’s mobile #: _________________________________________

Council Name/No.: _______________________________________________________________________________________________________Unit No.: ____________________

Health/Accident Insurance Company: ________________________________________________________ Policy No.: ___________________________________________________

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Part B2: General Information/Health History

Full name: ___________________________________________

Date of birth: _________________________________________

High-adventure base participants:

Expedition/crew No.: _______________________________________________

or staff position: ___________________________________________________

Reason: _______________________________________________

Approved by: ____________________________________________

Date: _________________________________________________

INHALER? Exp. date (if yes) ___________________________________

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Part C: Pre-Participation Physical

C

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