Participation Waiver And Indemnity Form For Minors

Event Name* This field is required.Which event does this waiver cover?

Event Start Date* This field is required.

{eventName}

{eventStartDate} - {eventEndDate}

Parent/Guardian* This field is required.

First Name

Last Name

Please enter your email

Please enter your phone

Adult ParticipantI will attend the {eventName} with my child and I am willing to provide transportation for Scouts and/or adults with the understanding that each person must wear a seat belt when traveling in the vehicle. I have on file with Troop 133 or 1033 verification of appropriate automobile insurance coverage. I acknowledge the Activity Waiver detailed above will also apply to me with my signature below.

YESNO

TransportationWe need adult participants to help transport Scouts to and from our outings. Please let us know how many total seats you have in your vehicle.

Total number of seat belts in vehicle

Number of MinorsHow many minors will be attending {eventName}?

Minor Participant

First Name

Last Name

Permission to Participate ({minorParticipant_1:first}){minorParticipant_1} will attend and has my permission to attend the {eventName} trip, outing or activity on {eventStartDate} - {eventEndDate}. In consideration of the benefits to be derived, and in view of the fact that the Boy Scouts of America is a nonprofit organization, membership in which is voluntary, and understanding that travel to and participation in Scouts BSA trips, outings and activities, involve inherent risk and dangers, I hereby, on behalf of my son or ward, (a) agree to participation in the above trip, outing or activity, (b) assume all risks associated with such trip or activity, and (c) release and agree to hold harmless from any or all claims for injury and/or damages of any nature (whether to me or my son or ward or others) that may arise from participation in this trip, outing or activity (i) the Boy Scouts of America, including Troop 133, Troop 1033, and all other affiliated or associated organizations or entities; (ii) all officers, directors, agents, employees and volunteers of the above organizations and entities; (iii) all adult leaders of Troop 133, Troop 1033 and all adults participating in the above trip, outing or activity; and (iv) all scouts participating in the above trip or activity and their parents or guardians.

Enter your initials for consent

Medical Record ({minorParticipant_1:first})Does the minor participant, {minorParticipant_1} have an Annual BSA Health and Medical Record, which includes permission to treat a minor, filed with the Troop?

Yes, my child is a fully registered Scout with the Troop.

No, my child is a Guest or does not have an Annual BSA Health and Medical Record with the Troop.

Guest: Medical Permission to Treat Minor ({minorParticipant_1:first})In case of emergency, I understand every effort will be made to contact me, and in the event that I can not be reached, I hereby give my permission to the physician selected by the leaders in charge to secure proper treatment; including: hospitalization, anesthesia, surgery, injections, or medications for the participant. If participant is under 18 years of age, then this form must also be signed by parent/guardian.

Address

Guest of which Scout?

Emergency Contact

Emergency Contact Phone

Physician Name

Physician Phone

Insurance Carrier

Policy Number

Medical Condition ({minorParticipant_1:first}){minorParticipant_1} has a medical condition that requires medications to be taken during this outing. I understand that I am responsible to present the medications in original containers, including prescription bottles with Scouts name and dosage amounts, to the designated Scout Leader appointed to control medications for the outing. All of the medications should be enclosed in a zip-lock type of clear bag with the Scouts name, full instructions for dosage times and dosage amounts written on the outside.

YESNO

Medical Condition ({minorParticipant_1:first})The following are special medical conditions for {minorParticipant_1} related to this specific trip, outing or activity or other conditions and issues not listed on the Annual BSA Health and Medical Record filed with the Troop. (This may include short term illnesses):

Minor Participant 2

First Name

Last Name

Permission to Participate ({minorParticipant-2:first}){minorParticipant-2} will attend and has my permission to attend the {eventName} trip, outing or activity on {eventStartDate} - {eventEndDate}. In consideration of the benefits to be derived, and in view of the fact that the Boy Scouts of America is a nonprofit organization, membership in which is voluntary, and understanding that travel to and participation in Scouts BSA trips, outings and activities, involve inherent risk and dangers, I hereby, on behalf of my son or ward, (a) agree to participation in the above trip, outing or activity, (b) assume all risks associated with such trip or activity, and (c) release and agree to hold harmless from any or all claims for injury and/or damages of any nature (whether to me or my son or ward or others) that may arise from participation in this trip, outing or activity (i) the Boy Scouts of America, including Troop 133, Troop 1033, and all other affiliated or associated organizations or entities; (ii) all officers, directors, agents, employees and volunteers of the above organizations and entities; (iii) all adult leaders of Troop 133, Troop 1033 and all adults participating in the above trip, outing or activity; and (iv) all scouts participating in the above trip or activity and their parents or guardians.

Enter your initials for consent

Medical Record ({minorParticipant-2:first})Does the minor participant, {minorParticipant-2} have an Annual BSA Health and Medical Record, which includes permission to treat a minor, filed with the Troop?

Yes, my child is a fully registered Scout with the Troop.

No, my child is a Guest or does not have an Annual BSA Health and Medical Record with the Troop.

Guest: Medical Permission to Treat Minor ({minorParticipant-2:first})In case of emergency, I understand every effort will be made to contact me, and in the event that I can not be reached, I hereby give my permission to the physician selected by the leaders in charge to secure proper treatment; including: hospitalization, anesthesia, surgery, injections, or medications for the participant. If participant is under 18 years of age, then this form must also be signed by parent/guardian.

Address

Guest of which Scout?

Emergency Contact

Emergency Contact Phone

Physician Name

Physician Phone

Insurance Carrier

Policy Number

Medical Condition ({minorParticipant-2:first}){minorParticipant-2} has a medical condition that requires medications to be taken during this outing. I understand that I am responsible to present the medications in original containers, including prescription bottles with Scouts name and dosage amounts, to the designated Scout Leader appointed to control medications for the outing. All of the medications should be enclosed in a zip-lock type of clear bag with the Scouts name, full instructions for dosage times and dosage amounts written on the outside.

YESNO

Medical Condition ({minorParticipant-2:first})The following are special medical conditions for ({minorParticipant-2}) related to this specific trip, outing or activity or other conditions and issues not listed on the Annual BSA Health and Medical Record filed with the Troop. (This may include short term illnesses):

Minor Participant 3

First Name

Last Name

Permission to Participate ({minorParticipant-3:first}){minorParticipant-3} will attend and has my permission to attend the {eventName} trip, outing or activity on {eventStartDate} - {eventEndDate}. In consideration of the benefits to be derived, and in view of the fact that the Boy Scouts of America is a nonprofit organization, membership in which is voluntary, and understanding that travel to and participation in Scouts BSA trips, outings and activities, involve inherent risk and dangers, I hereby, on behalf of my son or ward, (a) agree to participation in the above trip, outing or activity, (b) assume all risks associated with such trip or activity, and (c) release and agree to hold harmless from any or all claims for injury and/or damages of any nature (whether to me or my son or ward or others) that may arise from participation in this trip, outing or activity (i) the Boy Scouts of America, including Troop 133, Troop 1033, and all other affiliated or associated organizations or entities; (ii) all officers, directors, agents, employees and volunteers of the above organizations and entities; (iii) all adult leaders of Troop 133, Troop 1033 and all adults participating in the above trip, outing or activity; and (iv) all scouts participating in the above trip or activity and their parents or guardians.

Enter your initials for consent

Medical Record ({minorParticipant-3:first})Does the minor participant, {minorParticipant-3} have an Annual BSA Health and Medical Record, which includes permission to treat a minor, filed with the Troop?

Yes, my child is a fully registered Scout with the Troop.

No, my child is a Guest or does not have an Annual BSA Health and Medical Record with the Troop.

Guest: Medical Permission to Treat Minor ({minorParticipant-3:first})In case of emergency, I understand every effort will be made to contact me, and in the event that I can not be reached, I hereby give my permission to the physician selected by the leaders in charge to secure proper treatment; including: hospitalization, anesthesia, surgery, injections, or medications for the participant. If participant is under 18 years of age, then this form must also be signed by parent/guardian.

Address

Guest of which Scout?

Emergency Contact

Emergency Contact Phone

Physician Name

Physician Phone

Insurance Carrier

Policy Number

Medical Condition ({minorParticipant-3:first}){minorParticipant-3} has a medical condition that requires medications to be taken during this outing. I understand that I am responsible to present the medications in original containers, including prescription bottles with Scouts name and dosage amounts, to the designated Scout Leader appointed to control medications for the outing. All of the medications should be enclosed in a zip-lock type of clear bag with the Scouts name, full instructions for dosage times and dosage amounts written on the outside.

YESNO

Medical Condition ({minorParticipant-3:first})The following are special medical conditions for ({minorParticipant-3}) related to this specific trip, outing or activity or other conditions and issues not listed on the Annual BSA Health and Medical Record filed with the Troop. (This may include short term illnesses):

Minor Participant 4

First Name

Last Name

Permission to Participate ({minorParticipant-4:first}){minorParticipant-4} will attend and has my permission to attend the {eventName} trip, outing or activity on {eventStartDate} - {eventEndDate}. In consideration of the benefits to be derived, and in view of the fact that the Boy Scouts of America is a nonprofit organization, membership in which is voluntary, and understanding that travel to and participation in Scouts BSA trips, outings and activities, involve inherent risk and dangers, I hereby, on behalf of my son or ward, (a) agree to participation in the above trip, outing or activity, (b) assume all risks associated with such trip or activity, and (c) release and agree to hold harmless from any or all claims for injury and/or damages of any nature (whether to me or my son or ward or others) that may arise from participation in this trip, outing or activity (i) the Boy Scouts of America, including Troop 133, Troop 1033, and all other affiliated or associated organizations or entities; (ii) all officers, directors, agents, employees and volunteers of the above organizations and entities; (iii) all adult leaders of Troop 133, Troop 1033 and all adults participating in the above trip, outing or activity; and (iv) all scouts participating in the above trip or activity and their parents or guardians.

Enter your initials for consent

Medical Record ({minorParticipant-4:first})Does the minor participant, {minorParticipant-4} have an Annual BSA Health and Medical Record, which includes permission to treat a minor, filed with the Troop?

Yes, my child is a fully registered Scout with the Troop.

No, my child is a Guest or does not have an Annual BSA Health and Medical Record with the Troop.

Guest: Medical Permission to Treat Minor ({minorParticipant-4:first})In case of emergency, I understand every effort will be made to contact me, and in the event that I can not be reached, I hereby give my permission to the physician selected by the leaders in charge to secure proper treatment; including: hospitalization, anesthesia, surgery, injections, or medications for the participant. If participant is under 18 years of age, then this form must also be signed by parent/guardian.

Address

Guest of which Scout?

Emergency Contact

Emergency Contact Phone

Physician Name

Physician Phone

Insurance Carrier

Policy Number

Medical Condition ({minorParticipant-4:first}){minorParticipant-4} has a medical condition that requires medications to be taken during this outing. I understand that I am responsible to present the medications in original containers, including prescription bottles with Scouts name and dosage amounts, to the designated Scout Leader appointed to control medications for the outing. All of the medications should be enclosed in a zip-lock type of clear bag with the Scouts name, full instructions for dosage times and dosage amounts written on the outside.

YESNO

Medical Condition ({minorParticipant-4:first})The following are special medical conditions for ({minorParticipant-4}) related to this specific trip, outing or activity or other conditions and issues not listed on the Annual BSA Health and Medical Record filed with the Troop. (This may include short term illnesses):

Minor Participant 5

First Name

Last Name

Permission to Participate ({minorParticipant-5:first}){minorParticipant-5} will attend and has my permission to attend the {eventName} trip, outing or activity on {eventStartDate} - {eventEndDate}. In consideration of the benefits to be derived, and in view of the fact that the Boy Scouts of America is a nonprofit organization, membership in which is voluntary, and understanding that travel to and participation in Scouts BSA trips, outings and activities, involve inherent risk and dangers, I hereby, on behalf of my son or ward, (a) agree to participation in the above trip, outing or activity, (b) assume all risks associated with such trip or activity, and (c) release and agree to hold harmless from any or all claims for injury and/or damages of any nature (whether to me or my son or ward or others) that may arise from participation in this trip, outing or activity (i) the Boy Scouts of America, including Troop 133, Troop 1033, and all other affiliated or associated organizations or entities; (ii) all officers, directors, agents, employees and volunteers of the above organizations and entities; (iii) all adult leaders of Troop 133, Troop 1033 and all adults participating in the above trip, outing or activity; and (iv) all scouts participating in the above trip or activity and their parents or guardians.

Enter your initials for consent

Medical Record ({minorParticipant-5:first})Does the minor participant, {minorParticipant-5} have an Annual BSA Health and Medical Record, which includes permission to treat a minor, filed with the Troop?

Yes, my child is a fully registered Scout with the Troop.

No, my child is a Guest or does not have an Annual BSA Health and Medical Record with the Troop.

Guest: Medical Permission to Treat Minor ({minorParticipant-5:first})In case of emergency, I understand every effort will be made to contact me, and in the event that I can not be reached, I hereby give my permission to the physician selected by the leaders in charge to secure proper treatment; including: hospitalization, anesthesia, surgery, injections, or medications for the participant. If participant is under 18 years of age, then this form must also be signed by parent/guardian.

Address

Guest of which Scout?

Emergency Contact

Emergency Contact Phone

Physician Name

Physician Phone

Insurance Carrier

Policy Number

Medical Condition ({minorParticipant-5:first}){minorParticipant-5} has a medical condition that requires medications to be taken during this outing. I understand that I am responsible to present the medications in original containers, including prescription bottles with Scouts name and dosage amounts, to the designated Scout Leader appointed to control medications for the outing. All of the medications should be enclosed in a zip-lock type of clear bag with the Scouts name, full instructions for dosage times and dosage amounts written on the outside.

YESNO

Medical Condition 5The following are special medical conditions for ({minorParticipant-5}) related to this specific trip, outing or activity or other conditions and issues not listed on the Annual BSA Health and Medical Record filed with the Troop. (This may include short term illnesses):

Parent or Legal Guardian E-Signature* This field is required.Use curser (or finger if using tablet or phone) to electronically sign in the box.

Clear

Date Signed* This field is required.

Date

Hour

Minutes