Activity:____________________________________ Date: __________________________
PARTICIPATION WAIVER for my son, namely:
____________________________________
In consideration of the benefits to be derived, and since
the Boy Scouts of America is an educational institution, membership in which is
voluntary, and having full confidence that every precaution will be taken to
ensure the safety and well being of my Scout son, named above on the activity.
I agree to his participation and waive all claims against the leaders of this
trip, officers, agents, and representatives of the Boy Scouts of America, and
the Sponsor. Upon emergency, illness or accident during the activity identified
above, I understand every effort will be made to contact me. In the event that
I cannot be reached in a timely manner and our own doctor is not readily
available, the troop or unit leader of the activity has my permission to obtain
without delay medical treatment as judgment of medical personnel dictates.
Proper medical treatment may include hospitalization, anesthesia, surgery, or
injections of medication for my son.
Signature of Parent or Guardian:
____________________________ Date:_______________
Printed Signature of Parent or
Guardian:__________________________________________
EMERGENCY INFORMATION: (Required update for troop
Health and Medical Records)
During the activity identified, We/I can be contacted at the
following phone/locations:
(____)______________________or (____)____________________ If
we/I can not be reached please contact:
(name) ___________________________ (phone)
_______________________________
Scout’s physician ______________________ (phone)
____________________________
Scout’s Allergies:
Scout’s Currently prescribed medication:
_________________________________________
Instructions for dispensing this medication:
Family Medical Insurance: Company:______________________
Policy # :_______________ Group # _______
Please include any additional emergency contacts on
the back