ACTIVITY AND TOUR PERMIT OrangeCalifornia Stake

A Permit must be approved by the Bishop and Stake Presidency for all outings greater than one night, and for travel outside the immediate area. Bishop-only approval is sufficient for one-day outings, and for outings that include one overnight stay.

The Permit should be completed by the Tour Leader. Please print or type.

Today’s Date / Ward / Class or Quorum
Name of Advisor / Advisor Telephone Number
Number of Young Women Involved / Number of Young Men Involved / Number of Adult Leaders

Description of the Activity

Tour Leader / Tour Leader Phone Number
Departure Date and Time / Return Date and Time / Destination
Brief Description
Gospel Purpose
Method(s) of Transportation
□ Auto□ Bus□ Boat□ RV□ Truck□ Other:
Participants are not permitted to travel in the bed of a pick-up truck.

Adult Leaders

Name / Phone Number / Driver?
YESNO / Insurance Co. and Policy Number
Name / Phone Number / Driver?
YESNO / Insurance Co. and Policy Number
Name / Phone Number / Driver?
YESNO / Insurance Co. and Policy Number
Name / Phone Number / Driver?
YESNO / Insurance Co. and Policy Number
Name / Phone Number / Driver?
YESNO / Insurance Co. and Policy Number
Name / Phone Number / Driver?
YESNO / Insurance Co. and Policy Number
Name / Phone Number / Driver?
YESNO / Insurance Co. and Policy Number
Name / Phone Number / Driver?
YESNO / Insurance Co. and Policy Number

Following is a checklist of essential criteria and guidelines to assure a successful and safe activity. Please answer all applicable questions by circling “Yes”, “No” or “N/A” (Not Applicable).

Yes / No / N/A / Prior arrangements have been made for campsites, lodging and meals.
Yes / No / N/A / Each participant will be provided information regarding what to do if separated from the group.
Yes / No / N/A / Activity itineraries have been prepared.
Yes / No / N/A / All adult leaders are 21-years-old or older.
Yes / No / N/A / There is at least one adult leader for every six youth.
Yes / No / N/A / A priesthood leader will be present at all young women overnight camps.
Yes / No / N/A / Insurance coverage for all vehicles meets minimum legal requirements.
Yes / No / N/A / All drivers are licensed and are at least 21-years-old.
Yes / No / N/A / Each vehicle is in safe running condition.
Yes / No / N/A / Seat belts will be worn by each driver and all passengers.
Yes / No / N/A / All traffic rules and regulations will be obeyed, including traveling at safe speeds.
Yes / No / N/A / No vehicle will be overloaded.
Yes / No / N/A / Drivers agree not to allow riders on tailgates or in the back of truck or trailers.
Yes / No / N/A / Drivers agree to not allow riders to ride on the outside of vehicles.
Yes / No / N/A / A responsible adult with lifeguard and resuscitation training will accompany the group.
Yes / No / N/A / Proper precautions have been taken with respect to non-swimmers and beginning swimmers.
Yes / No / N/A / Boats are equipped with minimum safety equipment.
Yes / No / N/A / Boats will be operated only by experienced drivers.
Yes / No / N/A / A person qualified in first aid will accompany the group.
Yes / No / N/A / Adequate first aid equipment will accompany the group.
Yes / No / N/A / Transportation will be available to move injured participants to medical facilities.
Yes / No / N/A / A medical clearance is provided for all participants.
Yes / No / N/A / Parents and guardians have been advised of the nature, route and destination of the trip.
Yes / No / N/A / Families are advised as to where and how to contact participants in case of an emergency.
Yes / No / N/A / A Parent/Guardian Authorization Form has been completed for each minor-age participant.
Yes / No / N/A / An authorized BSA Tour Permit has been obtained for this activity.

Estimated Cost

Planned Expenses
Food$______
Transportation______
Admission/Camp Fees______
Other:______
Other:______
Other:______
Total$______/ Method of Financing
Ward Budget$______
Personal (annual camp only)______
Other (annual camp only)______
Total$______

Approvals

Bishop / Stake Presidency
Date / Date

Version 10/2006Page 1