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Backpack Consent
Klondike Consent
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ACTIVITY PARTICIPATION SLIP
(A.P.S.) TROOP 72, B.S.A.
BACKPACK/CAMPOUT -ROGERS PASS
AUGUST 21-22, 1999
A.P.S. DUE BY TUESDAY, AUGUST 17,
AT SCOUT ROOM
!THIS IS A LEGAL DOCUMENT,
SIGNATURES REQUIRED
!NOTE:
TAKE BOTH A PINK AND GREEN COPY, KEEP THE PINK COPY & RETURN THE GREEN
COPY
!NO |
TRIP DESCRIPTION:
SCOUTS WILL MEET AT THE SCOUT ROOM ON SATURDAY, AUGUST 21,
AT 8:00 AM TO DEPART FOR THE MOFFAT TUNNEL PARKING AREA TO HIKE TO ROGERS PASS
FOR AN OVERNIGHT CAMPOUT. THIS IS AN EASY, ONE MILE BACKPACK INTO THE
CAMPSITE, WHERE WE WILL SET UP CAMP. FROM THERE, SOME OPTIONAL HIKES INTO
MOUNTAIN LAKES AND SCENIC AREAS WILL BE ORGANIZED FOR THOSE WHO WANT TO GO. IT
IS A GREAT TIME OF YEAR TO SEE THE MOUNTAINS, BEAUTIFUL WILDFLOWERS AND ANIMALS,
AND HAVE A GREAT TIME. BE SURE TO EAT BREAKFAST BEFORE DEPARTING FOR THE TRIP ON
SATURDAY MORNING, AND BRING TWO SACK LUNCHES, ONE FOR SATURDAY AND ONE FOR
SUNDAY, (DON’T BRING PERISHABLE ITEMS IN YOUR LUNCH THAT NEED REFRIGERATION)
PLUS ANY SNACKS/GORP YOU WANT TO BRING FOR EXTRA ENERGY; AND TWO FULL, 1 QUART
WATER BOTTLES. SATURDAY DINNER AND SUNDAY BREAKFAST WILL BE PROVIDED BY PATROLS.
RETURN TO BOULDER WILL BE APPROXIMATELY NOON ON SUNDAY. BE SURE TO TAKE ADEQUATE
CLOTHING--SEE THE LIST OF REQUIRED/RECOMMENDED EQUIPMENT . REMEMBER THAT NIGHTS
CAN GET COLD IN THE MOUNTAINS AND RAIN CAN OCCUR IN THE AFTERNOONS. BE SURE TO
BRING EXTRA CLOTHING SPECIFIED BELOW IN CASE THE WEATHER TURNS BAD WHILE YOU ARE
ON THE HIKE. ALTERNATE PLANS WILL BE MADE IN CASE OF ADVERSE WEATHER. . NOTE:
THERE IS A MANDATORY PACK INSPECTION/SHAKEDOWN ON FRIDAY NIGHT, 8-20 AT 7PM.
BRING YOUR BACKPACK AND GEAR TO THE SCOUTROOM AND PLAN TO LEAVE IT THERE
OVERNIGHT. IF YOU ARE MISSING ITEMS YOU WILL BE TOLD WHAT TO BRING TO MEET THE
REQUIRED LIST. FEE IS $10 FOR FOOD; CHECKS PAYABLE TO TROOP 72
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ACKNOWLEDGEMENT OF RISK:
NOTE THAT THIS TRIP MAY POSE
CERTAIN RISKS OR HAZARDS BEYOND THE CONTROL OF THE TRIP SPONSORS,
ADVISORS, AND PARTICIPANTS WHICH MAY INCLUDE, BUT ARE NOT LIMITED TO THE
FOLLOWING:
mountain Hiking can result in
illness or serious injury; other risks include hypothermia, illness due to
altitude and exertion,. WEATHER MAY VARY FROM NEAR PERFECT TO RAIN, SNOW,
LIGHTNING, WIND IN A MATTER OF MINUTES, SO PREPARATION WITH ADEQUATE
CLOTHING IS ABSOLUTELY ESSENTIAL. Participants will be under supervision
of experienced advisors, It is expected that all participants will have
adequate equipment for such a trip, and that participants are in good
physical condition and able to participate adequately under such
conditions. Participants and parents/guardians of participants acknowledge
the rigors and demands of this trip and understand that such risks may be
inherent in the activity. While normal Scouting safety procedures and
guidelines are in effect at all times, it is acknowledged that certain
risks beyond the control of trip leaders and/or advisors may occur, and
that in recognition of such risks, I and/or my child consent to
participate in this event and accept the terms of the participation
authorization, informed consent, release of liability, and medical
treatment consent printed below: |
PLEASE COMPLETE THE OPPOSITE SIDE OF THIS FORM AND RETURN BY
AUGUST 17
RETURN THE GREEN COPY WITH $10 CHECK;
KEEP THE PINK COPY FOR REFERENCE AND INFORMATION.
. FOR ADDITIONAL INFORMATION, CONTACT:PRIS WAGENER,
SCOUTMASTER, 555-1212
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REQUIRED LIST OF EQUIPMENT |
BACKPACK
SLEEPING BAG AND FOAM PAD/PILLOW
SMALL DAY PACK OR WAIST PACK
PERSONAL EATING UTENSILS, CUP, BOWL
RAIN COAT/PANTS
WINDBREAKER WITH HOOD (nylon or gortex
WARM FLEECE OR DOWN SWEATER/JACKET
polypropylene sock liners and/or high bulk acrylic socks,
such as THORLO (2 PAIR MINIMUM)
HEAVY WOOL OR THORLO HIKING SOCKS
--(NO COTTON SOCKS)
HIKING BOOTS OR ATHLETIC SHOES
HIKING SHORTS AND/OR LONG PANTS
2- 1 QUART PLASTIC WATER BOTTLES
"SPACE BLANKET" (mylar aluminized plastic)
BASEBALL CAP OR HAT
WOOL HAT/SKI CAP
GLOVES OR MITTENS
SMALL PERSONAL FIRST AID KIT
PERSONAL MEDICATIONS/PRESCRIPTIONS
FLASHLIGHT & EXTRA BATTERIES
SUNSCREEN SPF30;
CHAPSTICK SPF 30
WRAPAROUND SUNGLASSES, UV FILTER LENSES with neck straps to
prevent loss.
SNACKS/MUNCHIES, "GORP" IN PLASTIC ZIP LOCK BAGS:
(INCLUDE HIGH SUGAR CANDIES SUCH AS LEMON DROPS, AND FRUCTOSE BASE CANDIES,
RAISINS, DRIED FRUIT, PEANUTS, CHEESE) .
2 SACK LUNCHES (NO PERISHABLES)
STUFF SACKS TO STORE CLOTHING, ETC.
CAMERA/FILM (OPTIONAL)
INSECT REPELLENT (DEET OR EQUIVALENT)
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PARTICIPATION AUTHORIZATION, 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 TRIP AS PROPOSED ABOVE, AND FURTHER UNDERSTAND
THE POTENTIAL RISKS INHERENT IN SUCH TRAVEL AND PARTICIPATION AS DESCRIBED
ABOVE, AND/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 EXPLORER 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 BOY SCOUTS OF AMERICA, TROOP 72, VENTURING
CREW/SEA SCOUT SHIP 72 , TRIP SPONSORS, ADVISORS, LEADERS, OTHER TRIP
PARTICIPANTS, SACRED HEART OF JESUS CATHOLIC CHURCH, 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, INCLUDING BUT NOT LIMITED TO
MEDICATIONS SUCH AS ACETAMINOPHEN, IBUPROFEN, ANTACIDS, ANTIDIARRHEALS,
ANTIHISTAMINES, UNLESS SPECIFICALLY DECLINED IN SPACE BELOW. I WILL
LIST BELOW ANY ALLERGIES TO MEDICATIONS, FOODS, OR INSECTS, ETC., WHICH
MAY AFFECT MY CHILD AND/OR MYSELF; 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: |
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LIST ANY ALLERGIES OR CONTRAINDICATIONS FOR FOODS, MEDICATIONS, OR
HAZARDS SUCH AS INSECT STINGS/MEDICAL CONDITIONS WHICH MAY OCCUR DURING
THIS EVENT; ATTACH ADDITIONAL INFORMATION IF NECESSARY:
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*MEDICAL INSURANCE CERTIFICATION:
I HEREBY CERTIFY THAT MEDICAL INSURANCE IS IN EFFECT FOR
THE BELOW NAMED PARTICIPANT AS FOLLOWS:
NAME OF COMPANY/PROVIDER/HMO: POLICY NUMBER:
EXPIRATION
PHONE NUMBER OF COMPANY FOR AUTHORIZATION IF NEEDED: ( ) |
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PARENT AND PARTICIPANT SIGNATURES
I hereby certify that I have read, understand and agree
without reservation to the contents and requirements of this document and
the nature and possible risks of participation in this activity, and that
I accept and acknowledge such risks in light of the benefits of such
participation. :I/WE further certify that I am/we are legally empowered as
parent/guardian to consent to the terms of this document on behalf of the
minor child under age 18, named hereon.
WITNESS MY HAND AND SEAL THIS __________________DAY OF
____________1999, AT BOULDER, COLORADO, U.S.A.
x________________________________________________________
Signature of Participant
FULL NAME OF PARTICIPANT (PLEASE PRINT)
address: city zip phone NOTE: SIGNATURE(S) OF
EACH PARENT(S)/GUARDIAN(S) REQUIRED FOR PARTICIPANTS UNDER AGE 18
x PHONE
Signature of Parent/ Guardian
x PHONE
Signature of Parent/ Guardian
X nearest relative (or other person to contact if
parent/guardian
unavailable)_________________________________________________________
PHONE ( )________________
X SCOUTMASTER APPROVAL: X
(SIGNATURE)__________________________________________________
_______________________________________ |
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DRIVER INFORMATION
O I PLAN TO DRIVE AND PARTICIPATE IN THE TRIP ON SATURDAY/SUNDAY.
O OTHER ARRANGEMENT
(SPECIFY)__________________________________________________________
O NUMBER OF PASSENGERS I CAN TAKE (SEATBELT REQUIRED FOR EACH
PASSENGER)_______________
MAKE OF
VEHICLE______________________________________________________________YEAR___________________
DRIVER'S LICENSE
NUMBER________________________________________________________STATE________________
INSURANCE CERTIFICATION: I CERTIFY THAT LIABILITY INSURANCE IS IN
EFFECT FOR THIS VEHICLE IN THE AMOUNTS OF
$50,000, $100,000, AND $50,000 AS SPECIFIED IN B.S.A. AND STATE OF
COLORADO REQUIREMENTS.
ALL PASSENGERS ARE REQUIRED TO WEAR SEAT BELTS DURING TRAVEL: B.S.A.
POLICY
SIGNATURE OF DRIVER (REQUIRED)
x____________________________________________________DATE___________
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