Fillable Activity Consent Form - Boy Scouts Of America printable pdf download

Boy Scouts of America

Troop 509

Est. 1952

La Cañada Flintridge, CA

Activity Consent Form

The activity leader fills out the activity name, date(s), leader and emergency contact information, then all participants in the

activity - scouts, adults & siblings - complete the remainder of the form and give the signed form to the activity leader.

Parents should keep a copy of the form for the contact information at the bottom.

Name of scout/participant

, age

, has my consent to participate in

wilderness canoeing at Northern Tier near Ely, MN

8/3/16 to 8/12/16

name of activity

date(s)

Scout/participant’s medical insurance including policy number:

Any medical conditions, allergies to foods or drugs or plants, dietary restrictions, physical limitations, or anything

else the leaders should be aware of, including whether any prescription medications will accompany the scout:

Consent to OTC Medications

I give permission for the following over-the-counter medications, if available to the leaders, to be administered to

my child when appropriate (cross out any you do not want given to your child): for pain or fever - aspirin,

acetaminophen (e.g., Tylenol), ibuprofen (e.g., Advil); for nasal congestion - pseudoephedrine (e.g., Sudafed); for

diarrhea - loperaminde (e.g., Imodium); for sore throat - dyclonine hydrochloride (e.g., Sucrets); for burns -

benzalkonium, lidocaine, melaleuca oil; for insect bites - benzocaine; for cuts - neomycin, bacitracin, polymyxin B;

for upset stomach - antacid (e.g., Tums, Mylanta); for motion sickness - dimenhydrinate (e.g., Dramamine); for

allergies - diphenhydramine (e.g., Benadryl); for itching - chlorpheniramine (e.g., Chlor-trimeton).

Emergency Care

In case of an emergency involving my child, I understand reasonable efforts will be made to contact me. In the

event I cannot be reached, I give permission for my child to be treated by medical providers selected by the adult

leaders, including hospitalization, anesthesia, surgery, or injections of medication. Medical providers are

authorized to disclose to the adult leaders any examination findings, test results and treatment provided, for

purposes of medical evaluation, follow-up and communication with me, and/or determination of my child's ability to

continue in the program activities.

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 give consent for my child

(or myself) 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 leaders, 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.

Parent signature

Printed name

Date

names, telephone numbers and email addresses to contact in an emergency

Leader name, phone & email:

Emergency contact (not on trip):

Dale Walton 818-352-5505 h, 818-219-5080 c

Activity Consent Form - Boy Scouts Of America

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