Activity Permission Form
Complete this form to provide permission for participation in activities and to supply emergency contact information.
Participant Name
*
Troop #
Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Emergency Contact Name
*
Relationship to Participant
*
Emergency Contact Phone #
*
Please enter a valid phone number.
Format: (000) 000-0000.
Participant’s Date of Birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Participant Age
*
Address
*
City
*
State
*
Zip
*
Participant/Family Phone #
*
Please enter a valid phone number.
Format: (000) 000-0000.
Troop Leader Name
Troop Leader Phone #
-
Area Code
Phone Number
Activity Permission
I understand that my child’s participation in Trail Life activities involves the risk of potential personal injury, including death, due to the physical, mental, and emotional challenges in the activities offered. I have had the opportunity to obtain such information about those activities from the Troop leadership, venue activity coordinators, or other sources. I also understand that participation in these activities is entirely voluntary and requires participants to follow instructions and abide by all applicable rules and the standards of conduct, and have explained that to my child. In case of an emergency involving my child, I understand that efforts will be made to contact me. In the event I cannot be reached, permission is hereby given to the medical provider to secure proper treatment, including hospitalization, anesthesia, surgery, or injections of medication for my child. Medical providers are authorized to disclose protected health information to the adult in charge and/or any physician or health care provider involved in providing medical care to my child. Protected Health Information/Confidential Health Information (PHICHI) under the Standards for Privacy of Individually Identifiable Health Information, 45 C.F.R.§§160.103,164,501, etc. seq., as amended from time to time, includes examination findings, test results, treatment provided for purposes of medical evaluation of my child, follow-up and communication with me, and/or determination of my child’s ability to continue in the program activities. With appreciation of the dangers and risks associated with programs and activities including preparations for and transportation to and from the activity, on my own behalf and/or on behalf of my child, I hereby fully and completely release and waive any and all claims against Trail Life USA, the Charter Organization, the Troop leadership, the activity coordinators, and all employees, volunteers, related parties, or other organizations associated with Trail Life USA and/or any program or activity for personal injury, death, or loss that may arise. I have listed below any restrictions imposed on my child’s participation in connection
Restrictions (if none, check "none" checkbox)
Restrictions - None
None
Signature
*
Alternative Emergency Contact Name
Alternative Emergency Contact Relationship
Alternative Emergency Contact Home Phone #
Please enter a valid phone number.
Format: (000) 000-0000.
Alternative Emergency Contact Cell Phone #
Please enter a valid phone number.
Format: (000) 000-0000.
Submit Permission
Submit Permission
Should be Empty: