Activity Permission Form

Each participant is also required to have a medical form on file. If the activity or event is likely to exceed 72 hours, or the Trail Life activities or events include high altitude or high-exertion activities, then the TLUSA High Adventure Medical (which requires the examination by and the signature of a doctor or health care professional) form is required for each participant.

Participant's Name *
Participant's Name
Date Of Birth *
Date Of Birth
Address *
Address
Section
I understand that participation in Trail life activities involves the risk of potential personal injury, including death, due to the physical, mental, and emotional challenges in the activities offered. I have had the opportunity to obtain such information about those activities from the Troop leadership, venue, activity coordinators, or other sources. 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, and have explained that to my child. In case of an emergency involving my child, I understand that efforts will be made to contact me. In the event I cannot be reached, permission is hereby given to the medical provider to secure proper treatment, including hospitalization, anesthesia, surgery, or injections of medication for my child. Medical providers are authorized to disclose protected health information to the adult in charge 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. With appreciation of the dangers and risks associated with programs and activities including preparations for and transportation to and from the activity, on my own behalf and/or on behalf of my child, I hereby fully and completely release and waive any and all claims against Trail Life USA, the Charter Organization, the Troop leadership, the activity coordinators, and all employees, volunteers, related parties, or other organizations associated with Trail Life USA and/or any program or activity for personal injury, death, or loss that may arise. I have listed below any restrictions imposed on my child’s participation in connection with programs or activities and have advised my child to comply with those restrictions. Restrictions (if none, indicate “none”):
AGREEMENT: By entering text in the, "signature" field below, I agree that my electronic signature is the legally binding equivalent to my handwritten signature. Whenever I execute an electronic signature, it has the same validity and meaning as my handwritten signature. I will not, at any time in the future, repudiate the meaning of my electronic signature or claim that my electronic signature is not legally binding.
Date Of Signature *
Date Of Signature
If you are the participant please enter, "N/A" in this field.
Emergency Contact Info
Name *
Name