Permission Slip Format requested by many (fwd)

To: Scouts-L, Explorer-Net subscribers:
From: Bob Amick, Explorer Advisor, High Adventure Explorer Post 72
Boulder, CO

I have received so many requests for copies of this document, it would
seem prudent to post it for general access. The format has been
converted to ASCII so you can copy it back into whatever desk-top
publisher or word-processing format you choose. The document language is
copyrighted by Troop 72 and Explorer Post 72, Boulder, CO, HOWEVER,
permission to use the language is granted if attribution is provided
whenever it is used. Headers explain each section of the document.
Again it is printed on one page, back to back. Parents are given two
copies, one to keep and one to submit since it uses an "informed consent"
provision, wherein the trip and potential hazards are described, as well
as recommendations for equipment to take, fees, medical insurance in
effect, alternate persons to call if parents cannot be reached, etc. If
there are suggestions for improvements or changes, these too would be
appreciated. For International trips, signature of both parents is
absolutely required, and check into insurance to be sure that it covers
medical expenses in other countries and/or air ambulance service back to
the states. On SCUBA diving trips, for example, Explorers and Leaders
can get supplemental insurance that will cover air ambulance evacuation
back to the U.S., hyperbaric chamber, hospitilization, etc. It is good to
keep a folder with these documents attached for each Scout with the Trip
Leader so that if anyone does require medical attention, the consent form
goes with them to the hospital. On International or high adventure
trips, a physical exam form should also be in the folder to accompany the
consent form. It is also a good idea to make a second set of each
document to have one of the associate trip leaders keep, just in case the
primary set gets misplaced, or the trip leader is separated from the
group when the documents are needed.
(needless to say, you will need
to convert the lengthy legal text to 8 or 6 point type to get it to fit,
but most everything else can be in 10 point or thereabouts..depending on
your type style and word processor. We use the "albertus medium" font in
Word Perfect 6.0a. because it is clean and easily read in smaller fonts.)
*****************************************************************************
Permission slip header:
NOTE: This is a legal document, signatures required
PRE-KLONDIKE WINTER CAMPOUT
GOLDEN GATE STATE PARK, SOUTH OF ROLLINSVILLE, JANUARY 26-28, 1996
Activityq Permission Slip DUE BY TUESDAY, JANUARY 23, AT SCOUT MEETING
TRIP DESCRIPTION AND ACKNOWLEDGEMENT OF RISK
NOTE: SCOUTS MUST BE PROPERLY EQUIPPED: THOSE WHO DO NOT BRING REQUIRED
CLOTHING AND EQUIPMENT TO DEPARTURE MAY BE SENT HOME TO GET REQUIRED
ITEMS, SO DOUBLE CHECK YOUR LIST WHEN YOU PACK.
Scouts and Explorers will meet at the Scout Room, on Friday, January 26,
at 6:00 PM to depart for the Golden Gate State Park, South of
Rollinsville. This will be our "Pre-Klondike shakedown" to get sleds
and equipment ready and to practice Klondike Derby Skills for the
Klondike in February. It should be lots of fun, especially if you
haven't been to a Klondike before! This will be a full winter campout so
be sure to bring lots of warm clothing, and munchies. See your Patrol
Leader for more information or the equipment list below. There are
certain risks involved in winter camping such as frostbite or hypothermia
which can be prevented by proper clothing, drinking plenty of water, and
nutrition. If you or your
friends are getting very cold or your feet, hands or face begin to feel
numb, you may be getting frostbite. Put on more clothing, cover up
exposed skin, get inside a tent, eat some snack food and drink water,
warm if possible, and let your patrol
leader or a Scoutmaster know you are having problems with the cold.
------------------------------------------------------------------------
How to get to the campsite:
Golden Gate State Park is accessed by taking Boulder Canyon Highway 119
West to Nederland, then South past Rollinsville about 8 miles; watch for
large sign on right side of road; turn left (east) on Park Road. Stay to
the right, and watch for "Reverend's Ridge" campground sign. A separate
map is available for drivers from the scoutmaster.
Scouts will return to the Scout room by approximately 11:00 am on Sunday.
----------------------------------------------------------------------------
FOOD: COOKING WILL BE DONE BY PATROLS, FROM PRE-PLANNED MENUS.
FEE: $15.00 PER PERSON. (includes food AND PARK CAMPING FEES)
(Make checks payable to Troop 72
(PLEASE NOTE THAT FEES ARE NOT REFUNDABLE AFTER FOOD IS
PURCHASED). IF YOU ARE UNABLE TO ATTEND, YOU MUST NOTIFY THE
SENIOR PATROL LEADER BY 5:00 PM 1-25-96
__________________________________________________________________________
ADDITIONAL INFORMATION CONTACT:
SCOUTMASTER_____________________ AT PHONE____________________
Parents, family members and guests are encouraged to visit or
participate in the campout. In case of emergency call: (303)555-4433 to
get a message to a Scout or Leader on this trip
------------------------------------------------------------------------------
RECOMMENDED EQUIPMENT
Scouts should see the list of recommended camping equipment in the Scout
Handbook (or Scout Fieldbook) for general list of equipment. ESSENTIAL
ITEMS: Sleeping bag (with extra blanket or "Polarfleece" liner if bag
is not warm), foam pad, pillow, sleeping clothes (suggest sweatshirt with
hood, WOOL SKI HAT OR BALACLAVA, sweatpants or track"warmups" for
warmth and comfort while sleeping) ,warm jacket and/or windbreaker,
polarfleece or wool sweaters, heavy wool army surplus trousers or
polarfleece pants with nylon/goretex windpants, toilet kit, towel,
camera and film (optional). change of underwear, several pair of
polypropylene or high bulk acrylic synthetic sock liners, (DO NOT WEAR
COTTON JEANS OR SOCKS!!) and several pair of HEAVY WOOL SOCKS,
INSULATED WOOL FELT BOOTPACKS OR SNOWMOBILE BOOTS (SUCH AS "SORELS")OR
MOONBOOTS, (NOTE THAT REGULAR HIKING BOOTS ARE NOT WARM ENOUGH.) NO
ATHLETIC SHOES ALLOWED. COMPLETE CHANGE OF CLOTHING (SHIRT, UNDERWEAR,
PANTS, SOCKS), POLYPROPYLENE "LONG JOHNS" UNDERWEAR (NO COTTON), WARM
GLOVES OR MITTENS WITH WOOL OR POLARFLEECE LINERS, BACKPACK OR DAYPACK,
SUNSCREEN SPF 30, SUNGLASSES, FLASHLIGHT WITH EXTRA BATTERIES, WATER
BOTTLE/CANTEEN, SNACK FOOD ("GORP" SUCH AS A MIX OF PEANUTS, RAISINS,
CHEESE, M&MS, DRIED FRUIT, ETC.), 1-QUART WATER BOTTLE OR CANTEEN; ANY
MEDICATIONS REQUIRED.
PLEASE COMPLETE OPPOSITE SIDE OF THIS FORM AND RETURN BY JANUARY 23>
IF YOU ARE PLANNING TO GO, BE SURE TO NOTIFY THE S.P.L. AT THE
TROOP MEETING ON TUESDAY, JANUARY 16.

*************************************************************************
(page 2 is enclosed in "boxes" to separate portions of document)
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 SCOUT OR 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 AND EXPLORER POST 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
SUCESSFULLY 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, ANAESTHESIA,
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 OR ALTERNATE PERSON TO CONTACT.
**I have attached information about any special medical conditions or
medications required for the Scout/leader/guest participating.
------------------------------------------------------------------------------
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: ( )___________
)----------------------------------------------------------------------------
*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.

WITNESS MY HAND AND SEAL THIS __________________DAY OF ____________199_,
AT BOULDER, COLORADO, U.S.A.
x______________________________)_________________________________
SIGNATURE OF PARTICIPANT PRINT NAME OF PARTICIPANT
x___________________________________________________________
SIGNATURE OF PARTICIPANT PRINT NAME OF PARTICIPANT
)

X______________________________________________PHONE ( )______________
PARENT/GUARDIAN*
X______________________________________________PHONE ( )_____________
PARENT/GUARDIAN*
X_______________________________________________PHONE ( )____________
ALTERNATE PERSON TO CONTACT IF UNABLE TO REACH PARENT(S)

* SIGNATURE OF BOTH PARENT(S) OR GUARDIAN(S)
WHEN APPROPRIATE IS REQUIRED FOR PARTICIPANTS UNDER AGE 18
------------------------------------------------------------------------------
CHECK PAYABLE TO TROOP 72 ENCLOSED FOR TOTAL
AMOUNT..............................................$_______
-----------------------------------------------------------------------------
DRIVER INFORMATION
O I PLAN TO DRIVE TO THE CAMPOUT ON FRIDAY EVENING.
O I PLAN TO DRIVE FROM THE CAMPOUT ON SUNDAY ONLY.
O I PLAN TO DRIVE TO THE CAMPOUT ON FRIDAY, STAY OVER AND RETURN ON 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 minimum 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
X SIGNATURE OF DRIVER
(REQUIRED)x_________________________________DATE___________

*****************************************************************************
end of document copyright 1995, troop 72 and explorer post 72, boulder,
co, REPRODUCTION OF ALL OR ANY PORTION OF THIS DOCUMENT IS PERMITTED IF
ATTRIBUTION IS GIVEN TO THE ORGANIZATION.

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