Troop 171 Campout - Klondike Derby Troop P-Slip [Feb. 21 - 23, 2020]
I or my son or daughter have my permission to attend campout or activity listed. In granting this permission, I (we) waive all claims against Scouts BSA Troop 171, Scouts BSA, the Boy Scouts of America, or any of its leaders for any injury or illness my son, daughter or myself may sustain during this outing. In the event that I cannot be reached in an emergency, I hereby give permission to the physician selected by the adult leader in charge to hospitalize, to secure proper anesthesia, or to order appropriate injection or surgery for my child.

If I am involved in transporting Scouts on this outing, I will make sure that seat belts are provided for each passenger and driver. I also represent that the vehicle I will drive has adequate insurance coverage. (BSA requires $50,000/100,000 liability, $50,000 property damage).

In completing this form, I agree to all terms and conditions set forth in the BSA Medical Release Form on file with Troop 171.
Release *
Agree to all terms in the BSA Physical and Release Form and to statement above.
Parent *
Name of Parent/Adult Completing this Form:
Your answer
E-mail *
Address to send confirmation of information on this form.
Your answer
Trip Information:
What: Klondike Derby
When: February 21 - 23, 2020
Depart: Friday, Feb. 21, 2020 at 5:30 PM
Return: Sunday at approximately 11:00 AM
Where: Golden Gate State Park [south of Nederland on hwy 72]
Activities: Klondike Derby Competition
Food: Troop will provide meals. Patrols will need to plan on a cooked lunch on the sleds.
Cost (billed through Scout Accounts):
∞ $45.00 per Scout and Adult Leader ($30.00 registration fee plus food)
∞ $40.00 First Aid City Staff, or OA*member ($25.00 registration fee plus food)
∞ $10.00 per Webelos And Webelos parents attending on Saturday

Gear: Winter Camping Checklist - see troop Website. All Scouts on sled need to take the Ten Essentials
Drivers: We need drivers for Friday night and Sunday morning. Mountain driving conditions.
Distance: 30 miles [~1 hour with good roads]
1. This electronic Permission Slip
2. BSA Medical Parts A and B DATED WITHIN THE LAST YEAR (does NOT require a doctor's signature)
NOTE: Barb Allan should have your medical form. Will let Scouts and adults who are missing forms know via email.
This Form
Please check the following to let us know what this form is being used for.
Name *
Name for the Scout or adult for this form. If you are not on this pulldown list, enter your name in the next question.
Name if not on list
Enter your name here ONLY if it is not on the pulldown above.
Your answer
Status *
Scout Age
Please enter the age of the Scout on Klondike Derby day (adults and Webelos, please skip this question)
Scout Participation
Patrol members are needed to help with sleds. However, Scouts age 16 or over can volunteer to help with a city. IMPORTANT - we will offer our older Scout services to the troops running a city. However, it is not guaranteed that there will be a need.
Adult Help
Please check ALL that apply! NOTE: Klondike is a very large undertaking. We need a good number of adults to help make this happen!
Patrol *
Required so we can plan for the patrol sleds. If you don't know your patrol name, please download a roster and find out.
Parent/Scoutmaster Staff Camping?
Is parent camping with the troop for thus event? If yes, please complete a second survey with their information.Note: adults are only covered by BSA insurance if they are registered in Scouting. See Barb or Kathy for details.
Adult Registration
BSA Requires that ALL adults attending a campout MUST be registered in BSA if they attend combined trip over 72 hours in a years time. There is still time to get registered in order to attend this trip. See Barb Allan for forms and details.
Medical Information
Medication, Life-Threatening Allergies or Other Important Medical Conditions or Food Needs. Please List:
Your answer
If you can drive on this campout, please complete the following. If you cannot drive on this trip, please scroll down to the end of the form to complete the registration.
We need a large number of drivers for this trip. Please check all possible times that you can drive.
Yes, I Can Drive
No, I Cannot Drive
TO the campout (Friday at 5:30 PM)
FROM the campout (Sunday at 8:30 AM)
Type of Vehicle (Yr/Make/Model)
Your answer
Vehicle Information
Vehicle 4/AWD, High Clearance & Chains (Check all that apply)
Seat Belts
Number of seat belts available for driver and passengers
Cell Phone Number
XXX-XXX-XXXX or (none) Cell phone number in your possession while driving on this trip
Your answer
SPECIAL DRIVING/DEPARTURE INFORMATION FOR Stephanie Gould, Marta Turnbull or Greg Brown
Your answer
A troop tradition is the all-you-can eat pancake breakfast! This year, we will be using the Teen Center in Nederland. Great facility for this type of event.

To reward the Scouts for their hard work at Klondike, the adults take this on from beginning to end.

To make this work, we need parent help to:
• purchase supplies
• pre-cook the bacon and sausage
• cook the pancakes at Nederland
• serve
• cleanup
Pancake Breakfast Volunteer
If you are coming up to Nederland on Sunday to help with the pancake breakfast, please enter your name (last, first)
Your answer
Help and Items Needed
Please enter any or all of the following of which you can assist. More details will be coming from the hospitality folks as this gets organized.
Forms - Two Steps to Registration
Please acknowledge that there are TWO steps to registration by checking both boxes below. Step 1 - This Form. Step 2 - BSA Medical Parts A and B. No doctor signature required.
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