Informed Consent, Release Agreement, and Authorization
I understand that participation in Scouting activities involves the risk of personal injury, including
death, due to the physical, mental, and emotional challenges in the activities offered. Information
about those activities may be obtained from the venue, activity coordinators, or your local council.
I also understand that participation in these activities is entirely voluntary and requires participants
to follow instructions and abide by all applicable rules and the standards of conduct.
In case of an emergency involving me or my child, I understand that efforts will be made to
contact the individual listed as the emergency contact person by the medical provider and/or
adult leader. In the event that this person cannot be reached, permission is hereby given to the
medical provider selected by the adult leader in charge to secure proper treatment, including
hospitalization, anesthesia, surgery, or injections of medication for me or my child. Medical
providers are authorized to disclose protected health information to the adult in charge, camp
medical staff, camp management, and/or any physician or health-care provider involved in
providing medical care to the participant. Protected Health Information/Confidential Health
Information (PHI/CHI) under the Standards for Privacy of Individually Identifiable Health Information,
45 C.F.R. §§160.103, 164.501, etc. seq., as amended from time to time, includes examination
findings, test results, and treatment provided for 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.
(If applicable) I have carefully considered the risk involved and hereby give my informed consent
for my child to participate in all activities offered in the program. I further authorize the sharing
of the information on this form with any BSA volunteers or professionals who need to know of
medical conditions that may require special consideration in conducting Scouting activities.
With appreciation of the dangers and risks associated with programs and activities, on my
own behalf and/or on behalf of my child, I hereby fully and completely release and waive
any and all claims for personal injury, death, or loss that may arise against the Boy Scouts
of America, the local council, the activity coordinators, and all employees, volunteers,
related parties, or other organizations associated with any program or activity.
I also hereby assign and grant to the local council and the Boy Scouts of America, as well as their
authorized representatives, the right and permission to use and publish the photographs/film/
videotapes/electronic representations and/or sound recordings made of me or my child at all
Scouting activities, and I hereby release the Boy Scouts of America, the local council, the activity
coordinators, and all employees, volunteers, related parties, or other organizations associated
with the activity from any and all liability from such use and publication. I further authorize the
reproduction, sale, copyright, exhibit, broadcast, electronic storage, and/or distribution of said
photographs/film/videotapes/electronic representations and/or sound recordings without limitation
at the discretion of the BSA, and I specifically waive any right to any compensation I may have for
any of the foregoing.
