Form 680-673 - Activity Consent Form And Approval By Parents Or Legal Guardian
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1Activity consent Form And ApprovAl by pArents or legAl guArdiAn
This form is recommended for unit use to obtain approval and consent for Tiger Cubs, Cub Scouts, Webelos Scouts, Boy Scouts,
Varsity Scouts, Venturers, and guests (if applicable) under 21 years of age to participate in a den, pack, team, troop, or crew trip,
expedition, or activity. This form is required for use with flying plans and should be attached to the flying plan application. It is
recommended that parents keep a copy of the form and contact the tour leader in the event of any questions or in case emergency
contact is needed. Additional copies of this form along with the Guide to Safe Scouting are available for download from Scouting
Safely at
First name of participant and middle initial ____________________________ ___ Last name ______________________________
Address _______________________________________ Birth date (month/day/year) ____/____/______ Age during activity _______
Additional address (need street address if you have a P.O. box) ________________________________________________________
City __________________________________________________________________________________State _____ Zip _________
Has approval to participate in __________________________________________________________________________________
Dayhike at Buttermilk Falls, Delaware Water Gap
(Name of activity, orientation flight, outing trip, etc.)
From ______________ to ______________.
10/27/2013
10/27/2013
(Date)
(Date)
o
Without restrictions
o
Special considerations or restrictions: ________________________________________________________________________
Hold HArmless Agreement
I understand that participation in Scouting activities involves a certain degree of risk and can be physically, mentally, and emotionally
demanding. I have carefully considered the risk involved and have given consent for myself or my child to participate in this activity. I
also understand that participation in this activity is entirely voluntary and requires participants to abide by applicable rules and standards
of conduct. I 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 claims or liability arising out of this participation.
In case of emergency involving my child, I understand every effort will be made to contact me. In the event I cannot be reached, I hereby
give my permission to the medical provider selected by the adult leader in charge to secure proper treatment, including hospitalization,
anesthesia, surgery, or injections of medication for my child. Medical providers are authorized to disclose to the adult in charge 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.
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 tour leader with any questions:
Name _____________________________________________________________________________________________________
Scott Soldan
Phone _____________________________________________________ Email ___________________________________________
908-604-2325
buffasoldan@verizon.net
680-673
2011 Printing
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