2023-12-01 SportRock Lock-in

Informed Consent, Release Agreement, and Authorization


Activity: SportRock Lock-in (Sterling)
Date: December 1-2, 2023


The Troop will participate in a rock climbing lock-in (i.e. overnight) at SportRock in Sterling, VA. The lock-in begins at 8:00 PM on Friday, December 1 and ends no later than 8:00 AM on Saturday, December 2. Certified climbing instructors will be there to teach and monitor top rope belaying and rock climbing. Outside food is welcome and we will arrange for pizza, snacks, and drinks to be available. For more information on the facility see the gym website.


Scouts can be dropped off after 8:00 PM, but no later than 9:00 PM, on Friday and must be picked up no later than 8:00 AM on Saturday.


The activity fee at this time is $45. (This accounts for a partial subsidy by the Troop.) Feel free to invite siblings and friends (minimum age is 12 years). Adults are welcome to participate in the climbing as well (same fee).


Please register no later than Saturday, October 28 to ensure we have enough participation to proceed. We do need at least two BSA-registered adults to stay overnight for the duration of the event. Registration provides option to participate without a fee. A waiver form will be required for each participant (to be distributed later). Email Mr. Johnson with questions.


A current (within the last 12 months) BSA health & medical record (Parts A & B) is required for all participants--both Scouts and Adults. Bring paper form(s) with you to check-in and they will be returned at the end of the event. All adults attending must be registered with BSA and have completed BSA Youth Protection Training (YPT) in the past two years.


Emergency Contact Numbers during trip: Ron Johnson, 703-300-3611

Section 1 - Main Participant

Section 2 - Additional Participants

In addition to the main participant

Section 3 - Additional Contact Information

Include for anyone that you would like to receive emails about this event only. These email addresses will be used as the primary method of communications for this event.
Include for anyone that you would like to receive emails about this event only. These email addresses will be used as the primary method of communications for this event.
Include for anyone that you would like to receive emails about this event only. These email addresses will be used as the primary method of communications for this event.

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