2022-29-07 Dolly Sods Backpacking

Registration, Informed Consent, Release Agreement, and Authorization

Activity: Dolly Sods Backpacking
Date: July 29, 2022

Troop 51 will be going on a trip to Dolly Sods Wilderness in West Virginia. We will depart on 29th July 2022 at 6:30AM from the upper parking lot of Floris United Methodist Church. We will return on 31st July 2022 to Floris Elementary School  around 12:00 PM unless drivers return Scouts to their homes. Activities on the trip will include: wilderness fun, backpacking, camping.   Pets are not allowed. Siblings are not allowed.

Transportation will be on your own (or as arranged between families) and driving by private car.

All participants (Scouts and adults) should bring everything needed in a backpack.  The troop will provide instruction on what this means leading up to the event. Depending on the size of attendance, we’ll organize into Patrols to help maintain social distancing. Scouts and adults are asked to wear a mask, maintain social distance, and follow other guidance to be provided by the Troop. 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. A current (within the last 12 months) BSA health & medical record (Part B) must be on file for all participants. All adults attending must have completed BSA Youth Protection Training (YPT).

There is $15 per participant fee for this trip.

Emergency Contact Numbers during trip: Todd Jackson, ASM: [571] – [213] – [2433], Sameer Risbud [804]-[310]-[9310]


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

Section 7 - Alternate Date