Backpack 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, (DONíT 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

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

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)

 

 

 

 

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:

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:

 

*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: ( )

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)__________________________________________________ _______________________________________

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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