WAIVER OF RESPONSIBILITY

                                                                                      BOY SCOUT TROOP 412

 

                                                                Sponsor: Mt. Carmel United Methodist Church

 

Activity and date: Merit Badge Madness @ Sulins Farm

Place and time of departure: Pops Friday April 13, 2006.

 

Place and time of return:  Pop’s Sunday April 15, 2006 at 12:00 Noon Approx.

 

Additional info:  Adult Leaders:  Joe Hatcher, Bill Gibson

 

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                In consideration of the benefits to be derived and in view of the fact that 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 namely:

First name (Please Print)________________________

Last name (Please print) ________________________

On the activity named above, 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 of Troop 412.

 

                In event of an emergency, the troop leader of the activity named above has my permission to obtain medical treatment for this Scout at the nearest hospital or doctor at my expense.  In the absence of our own doctor, and as restricted on the Scout Medical Form on file with Troop 412.

 

 

                                                                                __________________________________  ______________

                                                                                (Signature of parent or guardian)                        (Date)

 

 

During the activity stated above I can be contacted at the following numbers and will accept long distance call charges.

Home: (     )                             ; Office: (      )                                other: (___)_________________

 

This Scout is highly allergic or sensitive to: __________________________________________________

What, if any, medications is this Scout taking? ________________________________________________

Any Special instructions for this medication? _________________________________________________

Do you want the leader to carry the medication? _______________________________________________

 

Use the back for additional information and for explanation of any other problems the activity leader should be aware of.

 

Date of last tetanus shot ______________________________

 

MEDICAL INSURANCE INFORMATION:

 

Company__________________________________________

 

Policy number: _____________________________________ 

 

Other pertinent information: _______________________________________________________________

 

______________________________________________________________________________________