PARENTAL INFORMED
CONSENT AGREEMENT
I/We understand that participation in activities and events offered through the Boy Scouts of America, Hawkeye Area Council, like most activities, involves a certain degree of risk that could result in injury, including fatal injuries. In consideration of the benefits to be derived and after carefully considering the risk involved, as well as in view of the fact that the Boy Scouts of America is an organization in which membership is voluntary, I/we hereby give consent for my/our son, ____________________________________________, to participate in activities and events offered through the Boy Scouts of America, Hawkeye Area Council. I/we hereby agree to waive all claims against the adult leaders, Pack 207, the Boy Scouts of America, and the Hawkeye Area Council, and their officers, members, participants, employees, agents, and representatives, which may arise from participation in such activities and events.
In case of emergency, I understand sincere efforts will be made to contact me at the phone number(s) listed below. In the event I cannot be reached, I hereby give permission to the physician selected by the adult leader in charge to secure medical treatment for my son, including but not limited to, hospitalization, anesthesia, surgery, or injections of medicine.
This form should be signed by both parents/guardians.
Dated this _____ day of ___________________________, 20___.
_____________________________________ ____________________________________
Parent/Guardian Parent/Guardian
CONTACT
INFORMATION
_____________________________________ ____________________________________
Telephone Number (home) Telephone Number (home)
_____________________________________ ____________________________________
Telephone Number (work / mobile ) Telephone Number (work / mobile)
_____________________________________ ____________________________________
_____________________________________ ____________________________________
_____________________________________ ____________________________________
Address Address
INSURANCE
INFORMATION
_____________________________________ ____________________________________
Child’s Physician Name of Insurance Plan
____________________________________
Policy No.
PARTICIPATION
PERMISSION FORM
I/we hereby authorize my/our son, ________________________________, to participate in the following activity:__________________________________________________________
___________________________________________________________________________________________________________________________________________________________.
I/we understand this activity will begin on __________________________________, 20___ and end on _________________________________________, 20___.
I/We understand that participation in this activity, like most activities, involves a certain degree of risk that could result in injury, including fatal injuries. In consideration of the benefits to be derived and after carefully considering the risk involved, as well as in view of the fact that the Boy Scouts of America is an organization in which membership is voluntary, I/we hereby give consent for my/our son to participate in this activity. I/we hereby waive all claims against the adult leaders, Pack 207, the Boy Scouts of America, and the Hawkeye Area Council, and their officers, members, participants, employees, agents, and representatives, which may arise from participation in this activity.
The cost of the activity is $______________. This permission form and the fees for the cost of this activity must be returned by _____________________, 20___.
In case of emergency, I understand sincere efforts will be made to contact me at the phone number(s) listed below. In the event I cannot be reached, I hereby give permission to the physician selected by the adult leader in charge to secure medical treatment for my son, including but not limited to, hospitalization, anesthesia, surgery, or injections of medicine.
This form should be signed by both parents/guardians.
Dated this _____ day of ___________________________, 20___.
_____________________________________ ____________________________________
Parent/Guardian Parent/Guardian