BOY SCOUTS OF AMERICA

TROOP 111

PLANTATION, FLORIDA

2012-13 ACTIVITY CONSENT FORM

(A) My son, (please print) ______has my permission to

participate in the ALL ACTIVITIES of Troop 111, Boy Scouts of America beginning SEPTEMBER 01, 2012 and ending AUGUST 31, 2013, and has my permission to ride to the activities with the leaders who are driving, or by other means as arranged by the Troop adult leadership.

(B) I consider him to be in good physical health. Listed below are any allergies or health precautions to be taken, physical limitations or special considerations or restrictions. Medications must be turned into the Scoutmaster or other designated adult to be dispensed ______

(C) HOLD HARMLESS AGREEMENT

I understand that participation in scouting activities involves a certain degree of risk and can be physically, mentally and emotional demanding. I have carefully considered the risk involved and have given consent for my son to participate in these activities. I also understand that participation in these activities is entirely voluntary and requires participants to abide by applicable rules and standards of conduct. I release the Boy Scouts of America, South Florida Council, Troop 111 and it’s leaders, chaperones and drivers, Plantation United Methodist Church and all other parties or organizations associated with these activities from any and all claims or liability arising out of this participation.

In case of emergency, involving my son, I understand every effort will be made to contact me. In the event I cannot be reached, I hereby give my permission to the medical provider selected by the adult leader in charge to secure proper treatment, including hospitalization, anesthesia, surgery, or injections of medication for my son. Medical providers are authorized to disclose to the adult in charge examination results, test results, and treatment provided for the purposes of medical evaluation of the participant, follow-up and communication with the participant’s parents or guardian, and/or determination of the participant’s ability to continue in the program activities.

(D) I expect him to conduct himself properly and conform to all Boy Scouts of America and Leadership safety policies. IF MY SON NEEDS TO BE SENT HOME DUE TO POOR CONDUCT OR INAPPROPRIATE BEHAVIOR, I WILL PROVIDE FOR HIS IMMEDIATE TRANSPORTATION FROM THE ACTIVITY TO HIS HOME.

Parent/Guardian Signature______Date ______

Parent/Guardian printed name ______

Address ______City ______Zip ______

Home Phone ______Cell Phone ______

Alternate Emergency Contact ______Phone______

______

TRANSPORTATION

Can you provide transportation for activities: YES _____YES-Local Trips Only ____ NO _____

If yes, please complete information on back side of this form

If yes: AUTO ____ VAN _____ SUV ____ TRUCK _____ (no passengers in pick up bed)

Make ______Model ______Year ______Tag # ______

Passenger Capacity: ______Do Not include driver as a passenger, all must be belted)

Do you have a trailer hitch? YES ___ NO ___ Ball size: _____ Towing capacity ______lbs

Luggage Rack (for canoe)? Yes ____ No____ Bike Rack? Yes ___ No___

Do you have liability insurance?: YES ___ NO___ Carrier: ______

Coverage Limits:______Minimum requirements: 50,000/100,000/50,000

Driver’s License # ______State, if not Fl ______

If you drive, we must have a copy of insurance card.

COPY RECEIVED: YES___ NO___ Expires ______

[Attach copy of insurance card here]

or staple to this form

With the exception of the activity date range, this form cannot be altered without the approval of the Troop Committee.
This form adheres to the recommendations set forth on BSA Form 680-673, 2011 printing

Revised 8.12.11as