Event Registration and Permission Slip

Which event are you signing up for?

In case of Emergency Contact:

Name

Phone Number

Email

Permission - Medical Consent

(By checking this box you are agreeing to the

Terms and Conditions to the right.)

Permission - Terms of Participation

(By checking this box you are agreeing to the

Terms and Conditions to the right.)

Comments

#1) Name of 1st Scout attending the event:

Scout #1 Full Name

Patrol Name

Med Ins Provider

Med Ins Number

Scout #2 Full Name

Patrol Name

Med Ins Provider

Med Ins Number

#1) Name of 2nd Scout attending the event:

Adult #1 Full Name

Patrol Name

Med Ins Provider

Med Ins Number

#1) Name of 1st Adult attending the event:

Adult #2 Full Name

Patrol Name

Med Ins Provider

Med Ins Number

#1) Name of 2nd Adult attending the event:

- MEDICAL CONSENT –

(We), the undersigned, parent/guardian of our Scout as listed above, a minor, do hereby authorize the TROOP ADULT LEADERSHIP 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 and surgeon licensed under the provisions of the Medical Practice Act on the medical staff of any 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 or treatment or hospital care being required but is given to provide authority and power on the part of our aforesaid agent(s) to give specific consent to any and all such diagnosis treatment or hospital care which aforementioned physician in the exercise of his/her best judgment may deem advisable.

This authorization is given in pursuant to the provisions of Section 25.8 of the Civil Code of California. Authorization shall remain effective until Nov 21, 2014, unless sooner revoked.

(I) (We) hereby authorize any hospital which has provided treatment to the above named minor pursuant to the provisions of Section 25.8 of the Civil Code of California to surrender physical custody of such minor to (my) (our) above named agent(s) upon the completion of treatment. This authorization is given pursuant to Section 1283 of the Health and Safety Code of California.

- TERMS OF PARTICIPATION IN TROOP ACTIVITIES -


In consideration of the services of the Boy Scouts of America, the Golden Empire Council, Troop 136, it’s staff and members, and all other persons or entities in any capacity on their behalf, herein collectively referred to as the BSA Troop 136 Team, I hereby agree to release and discharge the BSA Troop 136 Team, on behalf of myself, my children, my parents, my spouse, my heirs, assigns, personal representative and estate as follows:

1)  I acknowledge that camping, backpacking and other outdoor activities entails known and unanticipated risks, which could result in physical or emotional injury, paralysis, death, or damage to myself, to property, or to third parties. I understand that such risks simply cannot be eliminated without jeopardizing the essential quality of the activity. The risks include, but are not limited to: hiking and load carrying injuries, unpredictable weather and environmental conditions, wildlife and plants injuries, negligence caused by third parties and my own negligence.

2)  Furthermore, I acknowledge that the BSA Troop 136 Team seek to provide a safe environment and experience, but are not infallible. They might misjudge the weather or terrain, or give inadequate warning. They might be ignorant of a participant’s fitness, past experience or ability. I understand that there are different levels of participation available and I have chosen this activity myself, base upon my judgment and my skills. I have made no misrepresentation of my abilities to participate and use the equipment.

3)  I expressly agree and promise to accept and assume all of the risk existing in this activity for myself and/or my scout. My participation and that of my scout in this activity is purely voluntary and I elect to participate in spite of the risks.

4)  I hereby voluntarily release, forever discharge, and agree to indemnify and hold harmless the BSA Troop 136 Team from any and all claims, demands or cause of action, which are in any way connected with my participation in this activity or my use of provided equipment or facilities, including such claims which allege negligent act or omissions by the BSA  Troop 136 Team.

5)  By checking the appropriate box on the attached electronic form I acknowledge that I have carefully read this agreement and fully understand its contents. I am aware that this is a release of liability and a contract between self and the BSA Troop 136 Team and I accept it of my own free will.

6)  I understand that once the final date to register for an event has passed that I am not entitled to a refund, either whole or partial, should I decide to cancel. If payment has yet to be made and I should cancel after the final date to register then I furthermore understand and agree that I well be responsible for making that payment to cover my portion of the expenses.

IMPORTANT PLEASE READ: By using this sign-up form you and your scout are agreeing to the terms as listed below. Do not sign unless you fully understand it’s content. Should you have any questions please call the Scoutmaster or email her at Scoutmaster@Troop136.com.

Troop 136 Registration and Permission Slip Page

(You Can Now Register both scouts and adults, attending an event, on one Registration.

Please remember to put what patrol a scout is with and accurate insurance info)

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