Troop 667 Permission Slip (For Scouts)
Gateway District Camporee
October 7-9, 2011
On October 7-9, 2011 Troop 667 will participate in the Gateway District Camporee. The Fall Camporee is a special event in our district each year. Units will camp out over the weekend Friday through Sunday and Webelos are invited to camp with participating Troops. The location of Camporee this year is Horsetooth Reservoir and to reduce costs, we will be doing some conservation work, along with fun ac-tivities!
Don’t miss this great campout! We will meet at the church on Friday, October 7 at 4:00pm and leave promptly at 4:30. For more information, contact Mr. Shepard (303-635-1978 or djslyd01@aol.com).
THIS PERMISSION SLIP IS DUE BY SEPTEMBER 26, 2011
Detach and return this portion (with payment) by September 26, 2011
Note: Per Troop policy, no driver reimbursement is being provided for this outing.
Total: $
This permission slip due back with payment to Mrs. Thompson no later than September 26, 2011.
Date of Campout: October 7-9, 2011
Location: Horsetooth Reservoir near Fort Collins, Colorado
Leave from: Church Parking Lot, Friday, October 7, 2011, at 4:00 pm
Return to: Church Parking Lot, Sunday, October 9, 2011, around 12:30 pm
(Please complete other side!)
(Please print) List everyone who will attend the October 7-9, 2011 Gateway District Camporee. Put each attendee’s age and their cost (as show above).
This includes all camping fees, 3 meals on Saturday and 1 meal on Sunday.
$20
Per Attendee
Troop 667 Form C1011-8/0 $
Attendee Age Cost (see above)
$ $ $ $ $
I can transport Scouts (with seat belts):
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ToÌ
FromÌ
Round Trip Cell Phone: Type of vehicle: Number of seat belts (NOT including driver):Important: To transport Scouts, you MUST have auto insurance information on file with the Troop. See Joan Vierra if not. Cash Check From Troop Account Treasurer’s approval that your account has enough $$
Method of Payment:
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Whose? Treasurer’s Signature:
How many Troop tents do you need? Who will use them?
Want to assist 911 First Aid Teams?
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Yes, full dayÌ
Yes, half dayÌ
No Want to assist archery?Ì
Yes, full dayÌ
Yes, half dayÌ
NoRemember to bring:
Parent-Signed Hold Harmless Agreement Completed Medical Form
Saw (for cutting limbs and saplings—do NOT bring axe or hatchet) Pruning shears
Work gloves Water Bottle
Personal First Aid Kit
Sunscreen, Sunglasses, Chap Stick
Good walking shoes - hiking boots recommended Camera (optional)
Bug Spray
Flashlights w/ extra batteries Compass
Mess Kit Rain Gear Toiletries
Tent, ground cover, sleeping bag, sleeping pad Clothing for 3 days and 2 nights (dress in layers) Please note: Temps could be 20 degrees or colder at night!
Also check your 10 essentials list.
My child(ren), listed below, have my permission to attend the October 7-9, 2011 District Camporee
Child: Birthdate: Allergies:
Chronic Illnesses: _Regular Medications:
Restrictions or special problems:
Child: Birthdate: Allergies:
Chronic Illnesses: _Regular Medications:
Restrictions or special problems:
Child: Birthdate: Allergies:
Chronic Illnesses: _Regular Medications:
Restrictions or special problems:
Parent/Legal Guardian: Relationship:
Address: Home Phone:
Work Phone(s): Cellular: Pager:
Phone(s) where I can most likely be reached during this trip:
Doctor/Clinic:__________________________________________________________________ Phone:_________________
By signing this permission slip you further agree to promptly retrieve your child AT THE OUTING LOCATION if informed by leaders of the outing that your child is being sent home due to a significant violation of the rules of conduct of Troop 667 while on the outing. Should this occur, you agree that your child will forfeit all monies paid for this outing, and his transportation home will be pro-vided by you in a timely manor and at your expense.
Signed:
I, the above listed guardian and the undersigned, hereby give permission for my child(ren), listed above, to be given emergency treatment, in-cluding first aid and CPR, by a qualified person. I further authorize and consent to medical, surgical and hospital care, treatment and procedures performed for my child(ren) by a licensed physician or other hospital staff when deemed immediately necessary or advisable by a physician to safeguard my child’s health. In the event that I cannot be contacted, I hereby waive my right of informed consent for such treatment. I further give permission for my child(ren) to be transported by ambulance, aid car, air ambulance or other vehicle to an emergency center for treatment. I will assume any and all financial responsibility for the delivery of all such care and services.
7/21/2011
HOLD HARMLESS AND INDEMNIFICATION AGREEMENT
The undersigned hereby agrees to save, keep and hold harmless Larimer County, Larimer County
Parks and Open Lands Department, its officers, agents and employees from all claims for property
damage, personal injury or wrongful death arising out of, or in connection with, volunteering. By
executing this release, the undersigned acknowledges that he/she is fully aware of, and assumes, all
of the risks of injury associated with volunteering.
This agreement is specific to the Gateway District, Denver Area Council-Fall Camporee from Friday,
October 7, 2011 through Sunday, October 9, 2011 at Horsetooth Reservoir in Fort Collins, CO.
Date:____________________________________________
Signature:_________________________________________
Address: _________________________________________
Signature of parent (if child is under the age of 18):
_________________________________________________
Witness: __________________________________________
High-adventure base participants: Expedition/crew No.: __________________________________________________ or staff position: _______________________________________________________ 680-001 2011 Printing Rev. 2/2011
Full name:
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DOB:
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Allergies:
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Emergency contact No.:
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Annual BSA Health and Medical Record
Part A
GENERAL INFORMATION
Name ___________________________________________________________________ Date of birth ________________________________ Age _____________ Male Female Address _________________________________________________________________________________________________________________________ Grade completed (youth only) __________ City _____________________________________________________________________ State ____________ Zip ____________________________ Phone No. ________________________________ Unit leader ______________________________________________________ Council name/No. ___________________________________________ Unit No. ___________________ Social Security No. (optional; may be required by medical facilities for treatment) _______________________ Religious preference ______________________________ Health/accident insurance company __________________________________________________________ Policy No. ________________________________________________________
ATTACH A PHOTOCOPY OF BOTH SIDES OF INSURANCE CARD. IF FAMILY HAS NO MEDICAL INSURANCE, STATE “NONE.” In case of emergency, notify:
Name _________________________________________________________________________________ Relationship _____________________________________________________________ Address _________________________________________________________________________________________________________________________________________________________________ Home phone _________________________________________ Business phone _______________________________ Cell phone ___________________________________________ Alternate contact _________________________________________________________________________ Alternate’s phone ___________________________________________________
HEALTH HISTORY
Are you now, or have you ever been treated for any of the following: Allergies or Reaction to: Yes No Condition Explain Medication ____________________________________
Food, Plants, or Insect Bites _________________ _________________________________________________
Immunizations:
The following are recommended by the BSA.
Tetanus immunization is required and must have been received within the last 10 years. If
had disease, put “D” and the year. If immunized, check the box and the year received.
Yes No Date Tetanus ________________________ Pertussis _______________________ Diphtheria ______________________ Measles ________________________ Mumps _________________________ Rubella _________________________ Polio ____________________________ Chicken pox____________________ Hepatitis A _____________________ Hepatitis B _____________________ Influenza _______________________ Other (i.e., HIB) ________________
Exemption to immunizations claimed (form required).
Asthma Last attack: ____________ Diabetes Last HbA1c: ____________ Hypertension (high blood pressure) Heart disease (e.g., CHF, CAD, MI) Stroke/TIA
Lung/respiratory disease Ear/sinus problems Muscular/skeletal condition Menstrual problems (women only) Psychiatric/psychological and emotional difficulties
Behavioral disorders (e.g., ADD, ADHD, Asperger syndrome, autism) Bleeding disorders
Fainting spells Thyroid disease Kidney disease Sickle cell disease
Seizures Last seizure: ____________
Sleep disorders (e.g., sleep apnea) Use CPAP: Yes No Abdominal/digestive problems
Surgery Serious injury Other
MEDICATIONS
List all medications currently used. (If additional space is needed, please photocopy this part of the health form.) Inhalers and EpiPen information must be included, even if they are for occasional or emergency use only.
Medication _____________________________ Strength ________ Frequency ____________ Approximate date started ________________ Reason for medication ___________________ ________________________________________
Medication _____________________________ Strength ________ Frequency ____________ Approximate date started ________________ Reason for medication ___________________ ________________________________________
Medication _____________________________ Strength ________ Frequency ____________ Approximate date started ________________ Reason for medication ___________________ ________________________________________
Medication _____________________________ Strength ________ Frequency ____________ Approximate date started ________________ Reason for medication ___________________ ________________________________________
Medication _____________________________ Strength ________ Frequency ____________ Approximate date started ________________ Reason for medication ___________________ ________________________________________
Medication _____________________________ Strength ________ Frequency ____________ Approximate date started ________________ Reason for medication ___________________ ________________________________________
Administration of the above medications is approved by (if required by your state): ________________________ / _______________________
Parent/guardian signature and/or MD/DO, NP, or PA signature Be sure to bring medications in sufficient quantities and the original containers. Make sure that they are
NOT
expired, including inhalers and EpiPens. You
SHOULD NOT STOP
taking any maintenance medication. (For more information about immunizations, as well as the immunization exemption form, see Scouting Safely on Scouting.org.)High-adventure base participants: Expedition/crew No.: __________________________________________________ or staff position: _______________________________________________________ 680-001 2011 Printing Rev. 2/2011
Part B
INFORMED CONSENT AND HOLD HARMLESS/RELEASE AGREEMENT
I understand that participation in Scouting activities involves a certain degree of risk and can be physically, mentally, and emotionally demanding. I also understand that participation in these activities is entirely voluntary and requires participants to abide by applicable rules and standards of conduct.
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 protected health information to the adult in charge, camp medical staff, camp management, and/or any physician or health care provider involved in providing medical care to the participant. Protected Health Information/Confidential Health Information (PHI/CHI) under the Standards for Privacy of Individually Identifiable Health Information, 45 C.F.R. §§160.103, 164.501, etc. seq., as amended from time to time, includes examinationfindings, test results, and treatment provided for purposes of medical evaluation of the participant, follow-up and communication with theparticipant’s parents or guardian, and/or determination of the participant’s ability to continue in the program activities.
I have carefully considered the risk involved and give consent for myself and/or my child to participate in these activities. I approve the sharing of the information on this form with BSA volunteers and professionals who need to know of medical situations that might require special consideration for the safe conducting of Scouting activities.
I release 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.
Without restrictions.
With special considerations or restrictions (list) ____________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________________ TALENT RELEASE AGREEMENT
I hereby assign and grant to the local council and the Boy Scouts of America the right and permission to use and publish the photographs/ film/videotapes/electronic representations and/or sound recordings made of me or my child at all Scouting activities, and I hereby release 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 liability from such use and publication.
I hereby authorize the reproduction, sale, copyright, exhibit, broadcast, electronic storage, and/or distribution of said photographs/ film/videotapes/electronic representations and/or sound recordings without limitation at the discretion of the Boy Scouts of America, and I specifically waive any right to any compensation I may have for any of the foregoing.
Yes No
I understand that, 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.
If I am participating at
Philmont, Philmont Training Center, Northern Tier, or Florida Sea Base:
I have also read and
understand the risk advisories explained in Part D,
including height and weight requirements and restrictions,and understand
that the participant will not be allowed to participate in applicable high-adventure programs if those requirements are not met.
The participant has permission to engage in all high-adventure activities described, except as specifically noted by me or the
health-care provider.
Participant’s name _______________________________________________________________________________________________________ Participant’s signature __________________________________________________________________ Date ____________________________ Parent/guardian’s signature ______________________________________________________________ Date ____________________________
(if participant is under the age of 18)
Second parent/guardian signature ________________________________________________________ Date ____________________________ (if required; for example, CA)
This Annual Health and Medical Record is valid for 12 calendar months.
ADULTS AUTHORIZED TO TAKE YOUTH TO AND FROM EVENTS:
You must designate at least one adult. Please include a telephone number.
1. Name _________________________________________________________________ Telephone ______________________________________ 2. Name _________________________________________________________________ Telephone ______________________________________ 3. Name _________________________________________________________________ Telephone ______________________________________ Adults NOT authorized to take youth to and from events:
1. Name __________________________________________________________________________________________________________________ 2. Name __________________________________________________________________________________________________________________ 3. Name __________________________________________________________________________________________________________________