TROOP 746 PARENTS / GUARDIAN CONSENT FORM

EVENT: Biking the NCR Trail, and camping at Camp No-Ray

DATES: From: Friday, 16 March 2012 To: Sunday, 18 March 2012 COST: $15.00 food and supplies

LOCATION: CLOSEST HOSPITAL:

Camp No-Ray Carroll Hospital Center

19109 Saint Abrahams Ct. 200 Memorial Ave Ave

Hampstead, Maryland 21074 Westminster, MD, 21157-5799

Walt Clary Cell Number: 410-876-3000

410-812-5395 **Hospital may change due to availability


MEET AT: St. Joe’s Parking Lot ON: Fri. 03/16/12 AT: 6:00 PM we will leave promptly at 6:30PM

RETURN TO: St. Joe's Parking Lot ON: Sun 03/18/12 Approximately: 12:00 PM

SCOUTMASTER / ADULT LEADER:

SCOUTMASTER: Mr. Walt Clary CELL PHONE: 410-812-5395
ADULT LEADER: Mr. John Mudd CELL: 410-913-5624

Summary: 32.3 miles (38 minutes)

Time / Mile / Instruction / For / Toward
6:30 PM / 0.0 / Depart US-1, White Marsh, MD 21236 on US-1 [Belair Rd] (South-West) / 0.6 mi
6:30 PM / 0.6 / Keep RIGHT onto Ramp / 0.2 mi / MD-43
6:31 PM / 0.8 / Take Ramp (RIGHT) onto SR-43 [White Marsh Blvd] / 0.4 mi
6:32 PM / 1.2 / Take Ramp onto I-695 [Baltimore Beltway Outer Loop] / 7.5 mi / I-695
6:39 PM / 8.7 / Take Ramp (RIGHT) onto I-83 [Baltimore Harrisburg Expy] / 12.7 mi / I-83 / Timonium / York Pa
6:51 PM / 21.4 / At exit 27, turn RIGHT onto Ramp / 0.3 mi / MD-137 / Mt Carmel Rd / Hereford
6:52 PM / 21.7 / Keep LEFT to stay on Ramp / 65 yds / MD-137 / Hampstead
6:52 PM / 21.8 / Turn LEFT (West) onto SR-137 [Mt Carmel Rd] / 6.1 mi
7:00 PM / 27.9 / Turn RIGHT (North) onto SR-25 [Falls Rd] / 3.6 mi
7:06 PM / 31.5 / Turn RIGHT (North-East) onto Beckleysville Rd / 0.8 mi
7:08 PM / 32.3 / Turn at first Left onto St Abrahams Ct, Hampstead, MD 21074 / Proceed to driveway marked 19109. Proceed down driveway, bear to the left and take a left fork into the open field. Hopefully marked by small orange cones.

TROOP 746 PARENTS / GUARDIAN CONSENT FORM

EMERGENCY CONTACT: PHONE No ______

Cell ______

Alternate Contact ______Alternate’s Phone ______

MY SON ______SSN: ______

FROM: Fri 03/16/12 6:00pm TO: Sun 03/18/12 12:00ish pm LOCATION: St. Joe's

I am ABLE / UNABLE to drive TO / FROM the event. My vehicle can transport ______scouts / scouters including myself. I certify that I have the required (BSA/BAC) amount of auto insurance, my vehicle is in good operating order and that all passengers will have seat belts. I also confirm that I have read and will obey the (BSA/BAC) auto safety requirements.

VEHICLE MAKE:______car / wagon / truck / van TAG No. ______

I am ABLE / UNABLE to participate for the ENTIRE EVENT / FOLLOWING DAYS: ______
Hold Harmless Agreement

I understand that participation in the activity involves a certain degree of risk. I have carefully considered the risk involved and have

given consent for myself or my child to participate in the activity. I understand that participation in the activity is entirely voluntary and requires participants to abide by applicable rules and standards of conduct. I release the Boy Scouts of America, the local council, the activity coordinators, and all employees, volunteers, related parties, or other organizations associated with the activity from any and all claims or liability arising out of this participation.
In case of emergency involving my child, I understand every effort will be made to contact me. In the event I cannot be reached, I hereby give my permission to the medical provider selected by the adult leader in charge to secure proper treatment, including hospitalization, anesthesia, surgery, or injections of medication for my child. Medical providers are authorized to disclose to the adult in charge 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.

SIGNATURE: ______Date: / /

MEDICAL / HOSPITALIZATION INSURANCE INFORMATION

List of Medicines and attached directions for use:

List of Medicines my son is allergic to:

List of items my son is allergic to (bee stings, cats, dogs, hayfever, any foods, rashes)

Name of Insurance Company: ______

Policy Number: ______Group No: ______

Name of Insured: ______SSN: ______

Insured Employer Info: ______Tel. No: ______