Re: Permission slips

I have received so many requests for this form, I am taking the liberty of
posting it to the list, and hope that all who have requested it will be
able to pick it up from this posting. With apologies for the delay in
responding,and thanks for your patience.
This is a copyrighted document, however permission to utilize the language
is granted with attribution. It is recommended that you check with an
attorney in your state or locale to verify that the language is
appropriate and acceptable in your area and to make changes thereto if
necessary.

Best Wishes,

Bob Amick, Explorer Advisor, High Adventure Explorer Post 72, Boulder, CO
Longs Peak Council Exploring Training Chair

> In a message dated 97-06-14
13:36:58 EDT, you write:
> > << We have a permission form that all members of the Post and adult
> advisors/participants are required to sign. It is kept in a word
> processor and is changed to describe the specific events, risks, dates,
> locations, etc. A Scouter/Attorney assisted us in the design of the form.
> THe form also has the standard medical consent, informed consent and
> liability waiver, health insurance info, and a signature block for the
> participant, the parents if under 18, and the advisor approval.
> >>
>
ACTIVITY PARTICIPATION FORM
EXPLORER POST 72
ROCK CLIMBING
FIRST FLATIRON, BOULDER MOUNTAIN PARKS
SUNDAY, JUNE 8, 1997

this is a legal document, signatures required for all
participants

ACTIVITY DESCRIPTION AND RISK ACKNOWLEDGEMENT
TRIP DESCRIPTION:
Members of Explorer Post 72, sponsored by ______________________
Church, will participate in rock climbing trip on the First Flatiron, on
Baker's route. Although not a difficult climb, the rock face has a high
exposure requiring the use of belaying and climbing ropes and equipment
for safety. Only those Explorers who have taken the prescribed training
will be permitted to participate in the Climb. Explorers should meet at
the Chatauqua Parking lot at 8:00 AM on Sunday, June 8, and then will hike
to the climbing area from the lot.

ALL Participants (and parents of Explorers under age 18) must read and
sign this acknowledgement of risk. Trip leaders will be Andy Morris and
Jeff and Pris Wagener. Crew Leader will be Ciaran Loomis.

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:

WEATHER MAY VARY FROM NEAR PERFECT TO RAIN, LIGHTNING, WIND IN A MATTER
OF MINUTES, SO PREPARATION WITH ADEQUATE CLOTHING IS ABSOLUTELY
ESSENTIAL.
Rock Climbing may pose certain risks including but not limited to rockfal,
injury from falls, equipment malfunctions, or other risks associated with
such activities.
Participants will be under supervision of experienced advisors, however,
certain risks which may be beyond the control of said advisors and trip
leaders may occur. 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:

** FOR ADDITIONAL INFORMATION CALL:
___________ CIARAN, CREW LEADER AT 555-3986
ADVISORS: ANDY ; JEFF AND PRIS AT 555-1067
EMERGENCY CONTACT PHONE NUMBER : BOB 555-2342 (VOICE MAIL)

REQUIRED EQUIPMENT:
it is essential that all participants have the following equipment:
water-resistant windbreaker (nylon or gortex recommended) with hood,
rain/wind pants, two one-quart water bottles, "space blanket" (mylar
aluminized plastic), camera and film. fleece sweater or down vest,
polypropylene or high bulk acrylic socks, wool socks, sturdy hiking boots
or athletic shoes with lug or rubber grip soles, small personal first aid
kit; any personal medications/prescriptions ;insect repellent, small
bottle (cutters/deepwoods off, etc.) Flashlight and extra batteries; SACK
LUNCH, SUNSCREEN SPF30; WRAPAROUND SUNGLASSES, UV FILTER LENSES; Snacks,
munchies, "gorp" in plastic bags. Small DAY PACK OR WAIST PACK

SAFETY REQUIREMENTS AND CODE OF CONDUCT
In accordance with Longs Peak Council and BSA safety requirements, the
following rule shall be strictly adhered to at all times:
. All participants shall follow the Explorer Code and abide by the
rules/decisions of the Crew Leader and Advisors at all times; any serious
failure or violation of these rules shall be grounds for being returned
home prior to the end of the trip. Parents agree to accomodate such
arrangements if need arises. BSA requires participants to stay in groups
of no less than three persons at all times.

**PLEASE COMPLETE AND SIGN OPPOSITE SIDE OF THIS FORM

PLEASE KEEP ONE COPY AND SUBMIT THE COMPLETED COPY BY JUNE 8,1997

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, EXPLORER POSTS 72 AND 007 , TRIP
SPONSORS, ADVISORS, LEADERS, OTHER TRIP PARTICIPANTS, SACRED HEART OF
JESUS CATHOLIC CHURCH, SACRED HEART OF MARY 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:

*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.

WITNESS MY HAND AND SEAL THIS __________________DAY OF ____________1997,
AT BOULDER, COLORADO, U.S.A.
x___________________________________ADDRESS
city_________ PHONE ______________________
Signature of Participant

FULL NAME OF PARTICIPANT (PLEASE PRINT)
address:
city zip phone
NOTE: SIGNATURE(S) OF 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 EXPLORER ADVISOR APPROVAL: X
(SIGNATURE)__________________________________________________
_______________________________________

DRIVER INFORMATION
O I PLAN TO DRIVE AND PARTICIPATE IN THE CLIMB ON SUNDAY MORNING.
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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