Pennsylvania Dutch Council Bsa, C.o.p.e. Program Medical Information/informed Consent/hold Harmless Agreement printable pdf download

Pennsylvania Dutch Council

Boy Scouts of America

Medical Information/Informed Consent/Hold Harmless Agreement

Name: _____________________________Date___________ Date of Birth ___________

Address: ________________________________________________________________

Telephone # ________________________________

Name of personal Physician: ________________________________________________

In case of emergency contact: _______________________________________________

Phone: ________________________ or _______________________________________

List known Allergies ______________________________________________________

If you are allergic to bee stings, do you have a bee sting kit? _______________________

Do you wear contact lenses? _______

Are you pregnant?________________________

Have you had or do you have (circle if yes) Diabetes Asthma Angina Epilepsy

Chest pains Drug reactions high blood pressure heart murmur

Heart attack (if yes, date) _____________________

Have you ever had any serious disease or surgery? (If yes, explain and include date)

_______________________________________________________________________

Do you have any other medical conditions we should be aware of? _________________

_______________________________________________________________________

I understand that participation in the C.O.P.E. / Climbing/ rappelling activity offered through the Pennsylvania Dutch

Council, BSA, on SEP.20, 2008, involves a certain degree of risk that could result in injury or death. In consideration

of the benefits to be derived and after carefully considering the risk involved, and in view of the fact that the Boy

Scouts of America is an organization in which membership is voluntary, and having full confidence that precautions

will be taken to ensure the safety and well-being of my child, I give my permission for my child to participate in the

C.O.P.E. program. I herby release and hold harmless and waive any claims I may have against the Pennsylvania Dutch

Council, BSA, the National Council BSA and it s chartered affiliates, agents, servants, employees, officers from all cost

and expenses including but not limited to, attorney’s fees, reasonable investigations and discovery costs, courts cost,

and all other sums the above mentions persons may pay or become obligate to pay on account of any, all and every

demand for claim or assertion of liability, or any claim or action founded thereon arising or alleged to have arisen out

of your child’s us of real or personal property belonging to the Pennsylvania Dutch Council, BSA or by any actions or

omission by your child. In case of emergency, I understand every effort will be made to contact me. In the event I

cannot be reached, I herby give my permission to the physician selected the adult leader in charge to secure proper

treatment, including hospitalization, anesthesia, surgery, or injections of medication for my child.

This form must be signed by both parents/guardians

I am not under the influence of any chemical substance including alcohol. Understanding that any

physical activity involves a risk of injury I understand that my participation in the Pennsylvania

Dutch Council. BSA, C.O.P.E. program is entirely voluntary. I release the Pennsylvania Dutch

council BSA and all its employees from any claims or liability arising out of my participation.

The release does not, however, apply to any harm caused by negligence or willful misconduct of

the Pennsylvania Dutch Council, BSA or its employees.

Name (print)_____________________________Course date_____________________

Participant’s signature: ___________________________________ Date ___________

*If participant is under age 18, his or her parents or guardians must also sign below

Parent/guardian Signature)_________________________________________

File:ajpfiledccs2008 retreatMay First MailingCOPE Medical From.doc

Pennsylvania Dutch Council Bsa, C.o.p.e. Program Medical Information/informed Consent/hold Harmless Agreement

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