Parental Informed Consent Agreement

For Climbing/Rappelling Activities

I understand that participation in the climbing/rappelling activity offered through the Great Ponds District, Old Colony Council, BSA, Merit Badge University, on _______________ (date), involves a certain degree of risk that could result in injury or death. In consideration of the benefits to be derived and after carefully considering the risk involved, and in view of the fact that the Boy Scouts of America is an organization in which membership is voluntary, and having full confidence that precautions will be taken to ensure the safety and well-being of my (son/daughter), I have given my (son/daughter) _______________________________ (name) my consent to participate in the Climbing Merit Badge activity on __________________ (date).

I certify that this participant can meet the health and physical fitness requirement of the trip or activity.

I the event of illness or injury occurring to my (son/daughter) while involved in this trip or activity, I consent to X-ray examination, anesthesia, and/or medical or surgical diagnostic procedures or treatment considered necessary in the best judgment of the attending physician and performed by or under the supervision of a member of the medical staff of the hospital furnishing medical services. It is understood that in the event of a serious illness or injure, reasonable efforts to reach me will be made.

Medical Insurance Provider: __________________________

Telephone Number: __________________________

Group Name: ______________________________

Group Number: ______________________________

Doctor: (name and telephone number): _________________________________

Dentist: (name and telephone number): _________________________________

Additional information (e.g., allergies / medications): __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

(This form must have the signatures of both parents/guardians.)

__________________________________ _________________________________

Signature Signature

__________________________________ _________________________________

Telephone No. Telephone No.

__________________________________ _________________________________

Date Date