Bsa Medical Treatment Authorization Form

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LONG BEACH AREA COUNCIL
BOY SCOUTS OF AMERICA
CAMP TAHQUITZ
PARENT CONSENT
/MEDICAL TREATMENT AUTHORIZATION/PHOTO RELEASE
Fill in ALL 3 boxes below!
AUTHORIZATION AND CONSENT FOR MINOR TO PARTICIPATE
I/We, the undersigned parent(s)/guardian(s) of (FULL NAME) ________________________________________ a minor,
hereby make application for said minor for a place at CAMP TAHQUITZ SUMMER CAMP. I/we give permission for said
minor to attend and participate in all summertime activities at Camp Tahquitz. Said minor is amenable to such rules and
regulations as may be made by the Long Beach Area Council (LBAC) Executive Board, Camp Director, or its representatives.
It is expressly understood by the parents or guardians that the minor for whom this application is made is in a condition of
health that warrants his taking part in the event, and that the leader of this outing is hereby granted permission to take the
named member to a medical doctor for examination and treatment of any accident or illness that may arise during the term of
said outing.
AUTHORIZATION TO CONSENT OF TREATMENT OF MINOR
I/we do hereby authorize the LBAC Camp Director or his designate as agent(s) for the undersigned to consent to any X-ray
examination, anesthetic, medical or surgical diagnosis or treatment and hospital care which is deemed advisable by, and is to
be rendered under the general or special supervision of, any physician or surgeon licensed under the provision of the Medicine
Practice Act on the medical staff of a licensed hospital, whether such diagnosis or treatment is rendered at the office of said
physician or at said hospital.
It is understood that this authorization is given in advance of any specific diagnosis, treatment, or hospital care that the
aforementioned physician, in the exercise of his best judgment may deem advisable.
AUTHORIZATION FOR PHOTO RELEASE FOR PROMOTIONAL PUBLICATIONS
I/we understand that promotional pictures may be taken during camp activities. These promotional pieces may include camp
brochures, videos, LBAC publications, web sites, and slide shows. I/we authorize the Long Beach Area Council, Boy Scouts
of America LBAC, and the National Council, Boy Scouts of America, to use photography or video images of said minor for
future promotional and related program purposes. It is the policy of the LBAC not to identify youth members by full name or
address in any photographs, videos, or publications used.
These authorizations shall remain in effect for the event listed below.
PLACE: CAMP TAHQUITZ SUMMER CAMP DATES: FROM _____________TO________________
PARENT/GUARDIAN ____________________________
WITNESS________________________________
(Please print)
SIGNED__________________________________ Date______ SIGNED________________________ Date
AUTHORIZATION TO PERMIT USE OF FIREARMS
California Penal Code Section 12552 prohibits furnishing firearms to minors 18 without the express or implied permission of
the parent/guardian of the minor. Understanding this, I
do
do not give my permission for my child to use a firearm at
Camp Tahquitz.
HOME PHONE NUMBER_________________ BUSINESS PHONE NUMBER__________________
EMERGENCY PHONE NUMBER IN THE EVENT THAT PARENT/GUARDIAN CANNOT BE
CONTACTED
NAME____________________________RELATIONSHIP______________________PHONE_______
********************************************************************************************
RULES FOR ACCEPTANCE AND PARTICIPATION IN CAMP TAHQUITZ ARE THE SAME FOR EVERYONE
WITHOUT REGARD TO RACE, COLOR, NATIONAL ORIGIN, AGE, SEX, OR HANDICAP.
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