Fillable Activity Consent Form And Approval By Parents Or Legal Guardian printable pdf download

Rev 1/17/2016

ACTIVITY CONSENT FORM AND APPROVAL BY PARENTS OR LEGAL GUARDIAN

_______________________ __________________

_________________________________________

First name of participant

Middle initial

Last name

Birth date (month/day/year) _______/______ /_______

Age during activity: ____________

Street Address _____________________________________________________________

City_______________________________________________________________________

State__________________________________________________ Zip_________________

Has approval to participate in (name of activity, orientation flight, outing trip, etc.) __________________________________________

From ______________ to ______________

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 program activities.

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 or activity.

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 any participation restrictions. List all medications and dosage instructions. List any allergies. Write NONE if none of the prior

applies:

___________________________________________________________________________________________________________

Participant’s signature

Date

___________________________________________________________________________

________________________

Parent/guardian printed name Parent/guardian signature

Date

___________________________________________________________________________

_______________________

Area code and telephone number

(best contact and emergency contact)

Email (for use in sharing more details about the trip or activity)

____________________________________________

________________________________________________________

Contact the adult leader with any questions:

Name: ________________________________________________

Phone: ___________________________

Email: ________________________________________________

Activity Consent Form And Approval By Parents Or Legal Guardian

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