|
Search Inquiry Net
[ Back ] [ Home ] [ Up ]
Backpack Consent
Klondike Consent
Scout Books
Site Contents
| |
LAST NAME:________________FIRST NAME:____________________UNIT #__________ k-in
2000 KLONDIKE DERBY PARTICIPATION FORM
GOLDEN GATE STATE PARK, FEBRUARY 25-27, 2000 ARAPAHOE
DISTRICT, LONGS PEAK COUNCIL, B.S.A.
NOTE: THIS IS A LEGAL DOCUMENT, SIGNATURES REQUIRED FOR ALL PARTICIPANTS AND
BY PARENTS OF PARTICIPANTS UNDER AGE 18. MAKE ONE COPY PER PARTICIPANT AND TURN
IN WITH REGISTRATION FORM .
PARTICIPATION AUTHORIZATION, ACKNOWLEDGMENT OF RISK
INFORMED CONSENT, RELEASE OF LIABILITY, AND MEDICAL TREATMENT
CONSENT
* I
HEREBY CERTIFY THAT I HAVE READ AND FULLY UNDERSTAND THE NATURE AND SCOPE OF THE
ACTIVITY AS PROPOSED ABOVE, AND FURTHER UNDERSTAND THE POTENTIAL RISKS INHERENT
IN SUCH TRAVEL AND PARTICIPATION AS DESCRIBED ABOVE INCLUDING BUT NOT LIMITED TO
INJURY, ILLNESS OR DEATH FROM EXPOSURE TO COLD, WIND, PHYSICAL EXERTION,
COLLISION WITH SLEDS, AND RELATED ACTIVITIES;, AS EXPLAINED IN WRITTEN MATERIALS
OR IN MEETINGS WITH ADULT LEADERS. I THEREFORE AGREE TO AND ACCEPT THE RULES AND
GUIDELINES FOR PARTICIPATION IN THE ACTIVITY AS DESCRIBED ABOVE. (FOR SCOUT
OR VENTURING YOUTH UNDER AGE 18, PARENTAL/GUARDIAN CONSENT REQUIRED AS FOLLOWS):
I AUTHORIZE PARTICIPATION BY MY CHILD IN THE ACTIVITY DESCRIBED ABOVE, AND
CONSENT TO SUPERVISION OF MY CHILD BY ADULT ADVISORS/LEADERS DURING THIS EVENT.
I UNDERSTAND THAT NORMAL SCOUTING SAFETY PROCEDURES AND LEADERSHIP GUIDELINES
WILL BE IMPLEMENTED DURING THIS ACTIVITY. I FURTHER RECOGNIZE THAT CERTAIN RISKS
MAY BE INHERENT IN THE CONDUCT AND PARTICIPATION IN THIS ACTIVITY WHICH MAY BE
BEYOND THE CONTROL OF ADULT LEADERS AND/OR ACTIVITY SPONSORS. I FURTHER
CERTIFY THAT I AND/OR MY CHILD IS/ARE MEDICALLY AND PHYSICALLY CAPABLE OF
PARTICIPATION IN THIS EVENT AND IS/ARE MEDICALLY CLEARED BY A PHYSICIAN FOR
PARTICIPATION IN SUCH ACTIVITIES. IN RECOGNITION OF THE BENEFITS DERIVED BY
MYSELF AND/OR MY CHILD, AND IN THE EVENT OF ANY ACCIDENT RESULTING IN INJURY,
ILLNESS, DISABILITY, OR DEATH, OR PROPERTY LOSS OR DAMAGE, WHICH MIGHT OCCUR TO
MYSELF AND/OR MY CHILD, WHILE TRAVELING TO OR FROM, OR DURING THE CONDUCT OF,
THIS EVENT, I AGREE TO INDEMNIFY, AGREE NOT TO SUE, AND AGREE TO HOLD
HARMLESS, THE LONGS PEAK COUNCIL BOY SCOUTS OF AMERICA, GOLDEN GATE CANYON STATE
PARK, ALPHA PHI OMEGA/VENTURING CREW 492, ACTIVITY SPONSORS, ADVISORS, LEADERS,
OTHER TRIP PARTICIPANTS, AND ANY OR ALL AGENTS, EMPLOYEES, REPRESENTATIVES (OR
THEIR EXECUTORS OR HEIRS) ACTING ON BEHALF OF SUCH ORGANIZATIONS OR INDIVIDUALS,
FROM ALL CLAIMS DAMAGES, LOSSES, INJURIES AND EXPENSES ARISING OUT OF OR
RESULTING FROM PARTICIPATION IN THESE ACTIVITIES. I AGREE THE SITE OF ANY
LAWSUIT AND THE LAW GOVERNING ANY SUCH LAWSUIT SHALL BE COLORADO AND GOVERNED BY
COLORADO LAW. THE TERMS OF THIS AGREEMENT SHALL CONTINUE AND BE IN EFFECT AFTER
THE TRIP HAS ENDED. AS LIQUIDATED DAMAGES, I HEREBY AGREE THAT IF THE BOY SCOUTS
OF AMERICA OR ANY OF THE INDIVIDUALS OR ORGANIZATIONS NAMED ABOVE IS FORCED TO
DEFEND ANY ACTION, LAWSUIT OR LITIGATION INITIATED BY MYSELF, MY EXECUTORS, OR
MY HEIRS, ON MY FAMILY'S OR MY BEHALF, MY HEIRS OR EXECUTORS AND I AGREE TO PAY
THE BOY SCOUTS OF AMERICA AND ANY OR ALL SUCH ORGANIZATIONS OR INDIVIDUALS NAMED
ABOVE, ANY COSTS AND ATTORNEY'S FEES INCURRED IF THEY SUCCESSFULLY DEFEND SUCH
ACTION, LAWSUIT, OR LITIGATION.
*MEDICAL TREATMENT CONSENT:
IN THE EVENT OF INJURY OR ILLNESS TO MYSELF AND/OR MY CHILD, I CONSENT TO
ADMINISTRATION OF SUCH FIRST AID MEASURES AS MAY BE DETERMINED NECESSARY BY
ACTIVITY LEADERS, AND IF DETERMINED NECESSARY, I FURTHER CONSENT TO TRANSPORT BY
GROUND OR AIR AMBULANCE AND/OR REFERRAL TO PHYSICIANS AND ADMISSION TO HOSPITALS
. I FURTHER CONSENT TO EMERGENT MEDICAL TREATMENT FOR MYSELF AND/OR MY CHILD IF
DETERMINED NECESSARY, INCLUDING BUT NOT LIMITED TO, ANESTHESIA, INJECTION,
SURGERY, X-RAY, AND MEDICATION, IF I CANNOT BE CONTACTED IMMEDIATELY FOR SUCH
CONSENT. I UNDERSTAND THAT REASONABLE EFFORTS WILL BE MADE TO CONTACT ME IN SUCH
CASES. PHONE NUMBER WHERE I CAN BE REACHED DURING THIS EVENT IS LISTED BELOW:
MEDICAL CONDITIONS OF PARTICIPANT(S)
PLEASE LIST ANY SPECIAL MEDICAL CONDITIONS WHICH MAY BE IMPORTANT FOR EACH
PARTICIPANT
ALLERGIES: FAINTING:
CONVULSIONS SPECIAL MEDICATIONS:
BLEEDING: DIABETES:
ASTHMA: HEART PROBLEMS:
OTHER: SPECIFY:
*PARENTS AND PARTICIPANTS SIGNATURES:
I HAVE READ AND UNDERSTAND THE TEXT OF THE INFORMED CONSENT, WAIVER OF
LIABILITY, AND MEDICAL CONSENT ABOVE AND AGREE TO THE TERMS AS STATED WITHOUT
RESERVATION. I/We hereby certify that I/We am/are legally empowered to consent
to such permission on behalf of the minor child named below.
WITNESS MY HAND AND SEAL THIS __________________DAY OF ____________2000, AT
________________ COLORADO, U.S.A.
x ___________________________________________________________________signature
of participant
x ___________________________________________________________________
signature(s) of parent(s)/guardian(s)
x ___________________________________________________________________
signature(s) of parent(s)/guardian(s)
*SIGNATURE OF
PARENT(S) OR GUARDIAN(S) (REQUIRED FOR PARTICIPANTS UNDER AGE 18)
PARENTS NAME(S)
(PRINT)_____________________________________________________ADDRESS___________________
CITY______________________ZIP________________PHONE_________-_______________
PRINT NAME OF
PARTICIPANT_____________________________________________________
TROOP/PACK/POST/CREW UNIT NUMBER_____________________________UNIT SPONSORED
BY______________________________________________
UNIT LEADER
NAME______________________________________PHONE________________________ADDRESS_____________________________________
ALTERNATE PERSON TO CONTACT IN CASE OF EMERGENCY IF PARENTS CANNOT BE
CONTACTED:
_____________________________________________________________PHONE_________________________________
ADDRESS________________________________________________CITY________________ST___ZIP_____________
|
