Northern Star Council, Bsa Base Camp Participant Waiver printable pdf download

Northern Star Council, BSA

Base Camp Participant Waiver

NOTE: WE WILL RETAIN THIS FORM AT CAMP. Please keep a copy for your records.

This waiver needs to be completed by all youth & adults participating in activities at Base Camp.

Participants

Last Name:

____________________ First Name:

____________________

Date of Base Camp Participation:_____________

Talent Release:

I give my permission for Base Camp & Northern Star Council to use any photographic image taken of me to be used by

the Council in printed publications, on the internet or in other electronic formats for press or print purposes. If my image is

used, I hereby consent, without further consideration or compensation to the use of images taken of me for the purposes

of illustration, advertising or distribution of any manner. I understand that the images remain property of the Council and

that there will be no restrictions. I accept that no payment is due in respect of this authority and that no further payments

to me are required at any time.

Informed Consent and Hold Harmless/Release Agreement:

I understand that participation in Base Camp activities involve certain degrees of risk. I have carefully considered the risk

involved and have given consent for myself and/or my child to participate in these activities. I understand that participation

in these activities is entirely voluntary and requires participants to abide by applicable rules and standards of conduct. I

release, hold harmless and agree to indemnify Base Camp and 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.

I approve the sharing of the information on this form with BSA staff and volunteers who need to know of medical situations

that might require special consideration for the safe conducting of Base Camp activities.

In case of an emergency involving me or my child, I understand that every effort will be made to contact the individual

listed as the emergency contact person. 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 to the

adult in charge examination findings, test results, and treatment provide 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. I understand and agree that medical decisions related to care

and treatment may be based upon information supplied in the appropriate health form submitted.

I have read and understand all the information shared in this form. 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.

Participant’s name

_______________Date:_______________________

Participant’s signature

_____________________________________

(Parent or Guardian if under the age of 18)

PLEASE PRINT

Participant’s date of birth:

_________

Emergency Contact: Name____________________________________

Relationship to participant:______________________

Home/work Phone:____________________ Cell Phone:_____________________

Revised July 2011

Northern Star Council, Bsa Base Camp Participant Waiver

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