Scouts BSA Troop 39
May 2017 Zip Line & Camping
Trip #12 - Zip Line & Camping
Indicates required field
Full Name of Scout
Age During Activity
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 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 my child, I understand that efforts will be made to contact me.
In the event I cannot be reached, permission is hereby given to the medical provider to secure proper
treatment, including hospitalization, anesthesia, surgery, or injections of medication for my child.
Medical providers are authorized to disclose protected health information to the adult in charge and/
or any physician or health care provider involved in providing medical care to the participant.
Protected Health Information/Confidential Health Information (PHI/CHI) under the Standards for
Privacy of Individually Identifiable Health Information, 45 C.F.R. §§160.103, 164.501, etc. seq., as
amended from time to time, includes examination findings, 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
With appreciation of the dangers and risks associated with programs and activities including
preparations for and transportation to and from the activity, 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
NOTE: 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. List any
restrictions imposed on a child participant in connection with programs or activities below and
counsel your child to comply with those restrictions.
List participant restrictions, if any (or please type None if no restrictions):
By typing my name, phone number and email below, I am agreeing to the terms and conditions outlined in the consent form above and understand this electronic form is in lieu of a handwritten form.
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May 2017 Zip Line & Camping