Chief Seattle Council Boy Scouts of America

CHIEF SEATTLE COUNCIL BOY SCOUTS OF AMERICA UNIT ACTIVITY PERMISSION & RELEASE FORM -YOUTH PARTICIPANTS- (NOTE: This form may be copied or otherwise reproduced locally for unit events/activities)

p Unit No. Troop 474 Sub Group i h Circle one: pack, troop, team, post Circle one if applicable: Tigers, den, patrol s r e Tour Leader Kent Brooten Phone 253 631-5431 d a st e 28707 141 Ave SE, Kent, WA 98042

l Address t i n Other Key Contact Doug Gunderson Phone u y Address b

d Full description of activity (include at least departure and return date(s) and times, location(s), methods of transportation, whether any aquatics activities are e t included and descriptions of the key program elements involved) e l

p District Camporee @ King County Fairgrounds, Enumclaw. Meet @ Mr. Brooten’s @ 5:00 pm FRIDAY April 28 m o Return Sunday around 1:00 pm c e

b All Scouts to be in FULL UNIFORM o T

I have reviewed the above description of the planned activity and discussed it with my son or daughter. I recognize there are hazards, risks and dangers inherent in activities of this nature. In consideration of the benefits to be derived, and in view of the fact that the Boy Scouts of America is a youth service organization in which membership is voluntary, I hereby agree as follows: I give permission to participate in the activity described above which is being offered by the unit indicated. name of Cub, Scout, Varsity Scout or Explorer I assure the unit leadership that my son or daughter is in good health and is able to participate in all program elements related to this activity except as noted by me as follows:

) In the event I cannot be reached in an emergency, I hereby give permission to the physician selected by adult unit leadership to hospitalize, secure anesthesia, or s

( order injection or surgery for my son or daughter, and I accept financial responsibility for all such necessary medical treatment; and n a I release the Chief Seattle Council, the Boy Scouts of America, their officers, agents and representatives, and the leaders of this activity, from any and all liability, i

d claims and causes of action arising out of or in any way connected with my son's or daughter's participation in this activity. I further agree to indemnify the Chief r Seattle Council, the Boy Scouts of America, their officers, agents and representatives, and the leaders of this activity, for all claims or causes of action which are a

u initiated against them by, or on behalf of, my son or daughter, and which arise out of this activity. I agree that this release and indemnity agreement is binding upon

g me, my heirs and my personal representative, executor or administrator. r

o Signatures (both parents or guardian required)

( Date t n e

r Date a p Phone No. Home Emergency y b

d Family Medical Insurance Provider Policy No. e t e l

p Driver Information (to be completed if you are driving for this activity) m o Name of Driver Driver's License No. c e b Make/Model of Vehicle(s) o

T Insurance Provider Policy No.

Insurance Coverage Limits