Informed Consent & Permission Form
Urban packing (6/24)
SCOUT NAME: *
has my permission to attend the trip listed below
Your answer
Please read:
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, Troop 99, the activity coordinators, and all employees, volunteers, related parties, or other organizations associated with any program or activity.

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. If there are no restrictions, please type 'none'.
Limitations *
List Participant limitations, if any.
Your answer
Allergies & Medications: *
Please list any allergies/dietary restrictions, medications, including EpiPens, and inhalers that your son might take or use during the event
Your answer
In case of an emergency, please notify: *
Please list name and phone number
Your answer
Physician Information: *
Please list physician name and phone number
Your answer
Medical Insurance Information: *
Please list company name and provider and policy number
Your answer
Submit
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google.