2021-09-18 Camp Highroads (+ Fall Court of Honor)

Informed Consent, Release Agreement, and Authorization

Activity: Camp Highroads
Date: September 17-19, 2021

For our Fall Court of Honor and Campout, Troop 51 will be returning to Camp Highroads at 21164 STEPTOE HILL ROAD, MIDDLEBURG, VA, 20117.  We will depart on Friday 17 September 2021 at 5:00pm from the upper parking lot of Floris United Methodist Church and will return Sunday 19 September 2021. Transportation will be on your own (or as arranged between families) and driving by private car.  NO PETS ALLOWED

Registration due by September 8

Activities on Saturday will include: 

  • 9:00am-12:00noon high ropes
  • 12:00noon-1:00pm Lunch
  • 1:00pm-2:00pm Archery OR Mountain Boarding
  • 2:00-4:30pmpm Scout Skills
  • 5:30pm-8:00pm  Picnic & Fall Court of Honor. The Court of Honor ceremony will be held outdoors on the “ball field” Saturday night. Families should plan to bring their own picnic dinner, chairs and supplies.
  • 8:30-10:00pm German Spotlight Tag (bring a flashlight, dark clothes and/or camo)

Fees for this trip are non-refundable:

Camping $28.00 per person  | Grub Fee $15 per person | High Ropes; $59.00 per person  (up to 50 spots); Archery $16.00 (up to 25 spots); Mountain Boarding $19.00 (up to 20 spots)

PLEASE NOTE: Siblings participating in the High Ropes Course must be a current 6th grader or older, AND a parent must be in attendance.

All participants (Scouts and adults) should bring everything needed in a daypack.  Any Scout staying overnight or present without a parent should bring current (within the last 12 months) Annual Health and Medical Record (“Med Form”) (Parts A and B, with a copy of an insurance card) to be turned in to the lead ASM at the event; the form will be returned upon checking out or departure.  Scouts should bring their own lunch and refillable water bottle. Scouts and adults are asked to wear a mask, maintain social distance, and follow other guidance to be provided by the Troop and Camp Highroad. Use of Scout’s electronic devices during the event for a Scouting purpose MUST be approved by the Scoutmaster. Cell coverage is weak or spotty.

Emergency Contact Numbers during trip: Christine Saah: [703] – [861] – [9008] | or Sri Sharma [703]-[989]-[6947]

Section 1 - Main Participant

Section 2 - Additional Participants

In addition to the main participant

Section 3 - Additional Contact Information

Section 4 - Medical Information

Section 5 - Consent

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 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. I understand that COVID-19 is also a risk, particularly when gathering in groups; have received Troop guidance pertaining to gathering safely and agree to comply; and acknowledge that “Safe” is NOT the same as “Risk-Free.”

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 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 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 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.

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.

Troop 51 cannot continually monitor compliance of program participants or any limitations imposed upon them by parents or medical providers. However, so that leaders can be as familiar as possible with any limitations, list any restrictions imposed on a child participant in connection with programs or activities below and counsel your child to comply with those restrictions.

Section 6 - Payment

$ 0.00