January 2021 Day Outing
Activity Consent Sat 1/23 9-2pm Pachaug State Forest Youth Camping Area Voluntown CT
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Email address
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Your email
Name of youth who has permission to attend the event.
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Your answer
INFORMED CONSENT, RELEASE AGREEMENT, AND AUTHORIZATION
I understand that participation in Scouting activities involves the risk of personal injury, including death, due to the physical, mental, and emotional challenges in the activities offered. Information about those activities may be obtained from the venue, activity coordinators, or local council. I also understand that participation in these activities is entirely voluntary and requires participants to follow instructions and abide by all applicable rules and the standards of conduct.
In case of an emergency involving my child, I understand that efforts will be made to contact me. In the event I cannot be reached, permission is hereby given to the medical provider to secure proper treatment, including hospitalization, anesthesia, surgery, or injections of medication for my child. Medical providers are authorized to disclose protected health information to the adult in charge 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 examination findings, test results, and treatment provided for purposes of medical evaluation of the participant, follow-up and communication with the participant’s parents or guardian, and/or determination of the participant’s ability to continue in the program activities.
With appreciation of the dangers and risks associated with programs and activities including preparations for and transportation to and from the activity, on my own behalf and/or on behalf of my child, I hereby fully and completely release and waive any and all claims for personal injury, death, or loss that may arise against the Boy Scouts of America, the local council, the activity coordinators, and all employees, volunteers, related parties, or other organizations associated with any program or activity.
Restrictions
NOTE: The Boy Scouts of America and local councils cannot continually monitor compliance of program participants or any limitations imposed upon them by parents or medical providers. List any restrictions imposed on a child participant in connection with programs or activities below and counsel your child to comply with those restrictions.
List restrictions/Allergies (or "none")
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Your answer
List any medications your scout may need during this event (or "none")
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Your answer
Authorization and Contact info
By typing your name below, you are giving consent for your child to participate in this activity per this agreement and to follow the Troop 76 Code of Conduct and all BSA rules.
Parent / Guardian Permission (type full name)
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Your answer
Your best contact phone number
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Your answer
Your scout's cell phone number
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Your answer
Anything else we should know?
Your answer
Please answer the questions below for the scout attending the outing.
Are you currently experiencing, or have you experienced in the past 14 days, any of the following symptoms? Fever (100.4 F/37.8C or greater as measured by an oral thermometer)
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Yes
No
Required
Are you currently experiencing, or have you experienced in the past 14 days, any of the following symptoms? Cough
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YES
No
Required
Are you currently experiencing, or have you experienced in the past 14 days, any of the following symptoms? Shortness of breath or difficulty breathing?
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Yes
No
Required
Are you currently experiencing, or have you experienced in the past 14 days, any of the following symptoms? Sore throat
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Yes
No
Required
Are you currently experiencing, or have you experienced in the past 14 days, any of the following symptoms? New loss of taste or smell
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Yes
No
Required
Are you currently experiencing, or have you experienced in the past 14 days, any of the following symptoms? Chills
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Yes
No
Required
Are you currently experiencing, or have you experienced in the past 14 days, any of the following symptoms? Head or muscle aches
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Yes
No
Required
Are you currently experiencing, or have you experienced in the past 14 days, any of the following symptoms? Nausea, diarrhea, vomiting
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Yes
No
Required
In the past 14 days, have you been in close proximity to anyone who was experiencing any of the above symptoms or has experienced any of the above symptoms since your contact?
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Yes
No
Required
In the past 14 days, have you been in close proximity to anyone who has tested positive for COVID-19?
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Yes
No
Required
Have you been tested for COVID-19 and are waiting to receive test results?
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Yes
No
Required
Have you tested positive for COVID-19, or are you presumptively positive for COVID-19 based on your health care provider's assessment of your symptoms?
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Yes
No
Required
In the past 14 days, have you been on a commercial flight travelled outside the United States, or travelled (by any means) to a state identified by CT as requiring quarantine?
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Yes
No
Required
In the past 14 days, have you been in close proximity to anyone who has been on a commercial flight or traveled outside the United States?
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Yes
No
Required
Is there any reason why you feel you are at higher risk of contracting COVID-19 or experiencing complications from COVID-19 by entering the activity? If yes, please provide a brief explanation.
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Yes
No
Explanation:______________________________________________________________________________
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