!

Ute$District$Troops,$Crews$and$Teams$proudly$present$

$SURVIVING

THE POST ZOMBIE APOCALYPSE Fall$Camporee$

26$–$28$September$2014$CAMP$FALCON$Fort$Carson,$CO$

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The$Ute$District$Troops,$Teams$and$Crews$are$proud$to$sponsor$$

SURVIVING THE POST ZOMBIE APOCALYPSE

Fall$Camporee$26$–$28$September$2014$Camp$Falcon,$Fort$Carson,$CO$

BLANK&FORMS&PACKET&At#Check)In#Troop/Crew/Team#Leaders#MUST#have#the#following#ready#for#inspection/turn)in:##

! Registration!Worksheet!COPY!TURNED!IN!at!Check:in!(see!enclosed!form)!! Payment!Receipt!COPY!TURNED!IN!at!Check:in!(recommend!it!be!stapled!to!

Registration!Worksheet)!! Unit!Roster!COPY!TURNED!IN!at!Check:in!(see!enclosed!form)!! Tour!Plan!–!submitted!/!filed!online!in!accordance!with!Pikes!Peak!Council!policy!

:!A!COPY!of!the!Tour!Plan!is!TURNED!IN!at!Check:in.!Troops!will!not!be!permitted!to!stay!at!the!Ute!Spring!Camporee!without!a!Tour!Plan.!No!exceptions.!

! Covenant!Not!to!Sue!(Hold!Harmless)!must!be!filled!out!for!each!participant!and!TURNED!IN!at!Check:in!(see!enclosed!form).!**Enclosed!form!is!specific!for!this!event**!

! OA!Election!Sheet!COPY!TURNED!IN!at!Check:in!(recommend!it!be!stapled!to!OA!Call!Out!List)!

! OA!Call!Out!List!–!(name!of!Scouts!/!Adults!to!be!Called!Out!at!Campfire)!(see!enclosed!form)!TURNED!IN!at!Check:in!

! Signed!Permission!Slip!for!each!Scout.!Troop!Permission!Slips!must!be!brought!to!the!Camporee!and!be!available!for!inspection!at!Check:in,!but!will!be!kept!in!the!Leaders’!care.!

! Medical!Forms:!Medical!Forms!must!be!brought!to!the!Camporee!and!be!available!for!inspection!at!Check:in,!but!will!be!kept!in!the!Leaders’!care,!in!case!of!emergency.

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!Directions$to$Camp$Falcon:$

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CheckDIn$Procedures$!

Upon!arrival!at!Camp!Falcon!have!all!Check:In!documentation!available!for!review!and!turn:in.! !

Follow!Check:in!staff!instructions!as!they!direct!to!your!designated!campsite.!! Offload!vehicles! and!move!all!but!one!vehicle!or!trailer!to!the!designated!parking!area!(one!vehicle!or!trailer!may! be!kept!at!the!campsite!for!food!storage).!!

Final!check:in!and!verification!will!be!done! at!the!Check:in!area!at!the!white!tents!between!5:00!PM!and!8:00!PM,!26!September!2014.!(NOTE:$ Camporee$staff$must$have$an$accurate$count$of$who$is$camping$over$night$so$no$matter$ what$time$you$arrive$an$Adult$Leader$must$provide$designated$Camporee$staff$with$a$ roster)$(8:00$AM,$27$September$2014,$Check$In$for$Morning$Arrivals)!

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At$CheckDIn$Troop/Crew$Leaders$MUST$have$the$following$ready$for$inspection/turnDin:$$

Registration$Worksheet!COPY$TURNED&IN&at&Check9in&(see&enclosed&form)! Payment$Receipt!COPY$TURNED&IN&at&Check9in&(recommend&it&be&stapled&to&Registration&Worksheet)!

Unit$Roster!COPY$TURNED&IN&at&Check9in&(see&enclosed&form)! Tour$Plan!–!submitted!/!filed!online!in!accordance!with!Pikes!Peak!Council!policy!:!A#COPY$of#the#Tour#Plan#isTURNED&IN&at&Check9in.#Troops&will&not&be&permitted&to&stay&at&the&Ute&Spring&Camporee&without&a&&Tour& Plan.&No&exceptions.!

Covenant$Not$to$Sue!(Hold#Harmless)#must#be#filled#out#for#each#participant#and#TURNED&IN&at&Check9in&(see& enclosed&form).#**Enclosed&form&is&specific&for&this&event**!

OA!Election!Sheet!COPY$TURNED&IN&at&Check9in&(recommend&it&be&stapled&to&OA&Call&Out&List)! OA!Call!Out!List!–!(name#of#Scouts#/#Adults#to#be#Called#Out#at#Campfire)#(see&enclosed&form)&TURNED&IN&at& & Check9in!

Signed$Permission$Slip$for$each$Scout.!Troop#Permission#Slips#must#be#brought#to#the#Camporee#and#be#available# for#inspection#at#Check)in,#but#will#be#kept#in#the#Leaders’#care.!

Medical$Forms:!Medical#Forms#must#be#brought#to#the#Camporee#and#be#available#for#inspection#at#Check)in,#but# will#be#kept#in#the#Leaders’#care,#in#case#of#emergency.!

Early$Check$Out!–!Please!notify!the!Registration!Personnel!if!you!are!planning!an!early$(Saturday)$check$out$–!otherwise!we!will!assume!you!will!be!departing!Sunday!morning.!

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CheckDOut$Procedures$!

Before$notifying$the$designated$Staff$Personnel$that$you$are$ready$for$Check$Out$please$ensure$ the$following$items$are$completed:!$

Campsite!broken!down!and!all!vehicles!loaded! Detailed!policing!of!the!area!complete!–!All!Trash!is!to!be!taken!out!with!unit.! All!Fires!extinguished!(cold!out)! All!Scouts!accounted!for!

!Upon$completion$of$the$above$D$One$Adult$Troop$Leader$notifies$the$designated$Camporee$Staff$ personnel$that$the$unit$is$ready$for$checkout.$Camporee$Staff$Personnel$will$inspect$your$campsite. !

$Have$a$safe$trip$home!!

!

REGISTRATION$WORKSHEET!$

26!–!28!September!2014!Camp$Falcon,$Fort$Carson,$CO$

!$

Registration$is$01$August$thru$12$September$2014$at$a$fee$of$$12.00$per$person.!!A$late$fee$of$

$3.00$is$ assessed$between$13$–$23$September$($15.00$per$person).$There&will&be&no&

registrations&accepted&after&midnight& (MDT)&Tuesday,&23&September&2014.&There&will&be&no&

exceptions&to&this&policy.!

NOTE:$Cancellation$Policy$D$If$a$Scout/Scouter$cancellation$occurs$AFTER$Friday,$19$September$

2014$(the$last$ date$for$registration)$payment$date,$NO$fees$will$be$refunded$unless$

documented$by$a$medical$doctor$or$a$ death$occurred$in$the$family.!

Troops$/$Crews$/$Teams$

$

Troop/$Crew$/$Team$#:$ Scoutmaster/Crew$Leader:$$$ $ $

Phone:$$$$$$$$$$$D$$$$$$$$$$D$$$$$$$$$$$EDmail:$___________________@$$ ___________$$

Point$of$Contact$(if&different& from&above):$$$ $ $$

Phone:$$$$$$$$$$ D$$$$$$$$$$$D$$$$$$$$$$$EDmail:$___________________@$$ ___________!

$

Scout$Registration$Fee$$12.00$($15.00$Late$Fee)!

Number$of$Scouts$ X$$12.00$or$$15.00$each$ _________________$

Number$of$Adult$Leaders$ $ X$$12.00$or$$15.00$$$ $ __________$ $

$ $ $$Total$Due$=$$$$_____________________________!

$! !

Staple!a!copy!of!the!payment!receipt!here!

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Unit$Roster$UTE$Fall$Camporee$26$D$28$September$2014!

$

Troop$/$Crew$/$Team$#$$$ !$Patrol$Name$!! ! !!!!!!!1)!PL$$ !! ! ! !2)! !3)!! !4)!! !5)!! !6)!! !7)!! !8)!! !9)!! !10)!! !

Patrol$Name$!! ! !!!!!!!!1)!PL! ! ! !2)!!! !3)!! !4)!! !5)!! !6)!! !7)!! !8)!! !9)!! !10)!! !

!Patrol$Name$!! ! !!!!!!!1)!PL! ! ! !2)!! !3)!! !4)!! !5)!! !6)!! !7)!! !8)!! !9)!! !10)!! !

Patrol$Name$!! ! !!!!!!!!1)!PL! ! ! !2)!! !3)!! !4)!! !5)!! !6)!! !7)!! !8)!! !9)!! !10)!! !

!Adult$Scouter$Roster$

!1)!! !

!2)!! !

!3)!! !

!4)!! !

!

Campsite$Inspection$Form$$

Troop$#$_______$$!Please!enter!your!troop!number!above,!and!fill!in!patrol!names!on!chart!below.!!Post!this!inspection!form!at!your!campsite!in!a!visible!location,!secured!so!as!not!to!blow!away!or!get!rained!on.!!!!Campsite!inspections!will!take!place!on!Saturday!morning!between!9:00!and!4:00!PM.!!Thank#you!###$ $ $ $ $ $$$$ $ $$$$$ $$$Score$$ $ $ $ $$$$$$ $ $$$ $$$$$Possible$$Actual$Troop$Site$$ Criteria$Troop!Gateway!Displayed! ! ! ! !!!! 8! _______!Troop!Flag!Displayed! ! ! ! ! ! 8! _______!U.S.!Flag!Displayed! ! ! ! ! ! 8! _______!Colorado!Flag!Displayed!! ! ! ! ! 8! _______!Fuel!in!proper!container!or!locked! ! ! ! 8! _______!Fire!Extinguisher!(or!buckets!with!sand!or!water)! ! 8! _______!First!Aid!Kit!accessible! ! ! ! ! ! 8! _______!First!Aid!Kit!Visible! ! ! ! ! ! 8! _______!Total Possible Troop Site Score 64 _______ #Judge#Comments:#!!

Patrol$Sites$ (enter!patrol!names!at!top!of!patrol!columns)! ! !Criteria! Possible!

Score!Patrol!! Patrol! Patrol! Patrol!

Patrol!Flag!Displayed! 5! ! ! ! !Patrol!Name!Posted! 3$ $ $ $ $Duty!Roster!Posted! 5$ $ $ $ $Menu!Posted! 3$ $ $ $ $Food!Stored!Properly! 5$ $ $ $ $Dishwashing!Area! 5$ $ $ $ $Garbage!Contained! 5$ $ $ $ $Recycle!Containers! 2$ $ $ $ $Tents!properly!pitched! 3$ $ $ $ $Total$Patrol$Score$ 36$ $ $ $ $

#Judge#Comments:#!

Patrol$Average$______$ $ $ Troop$Total$______$!!! !

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Covenant$Not$to$Sue$$

Pikes$Peak$Council,$Boy$Scouts$of$America$"

$Youth$Section$(for$participants$who$are$younger$than$18)$$I,!______________________________________,!do!hereby!certify!that!I!am!the!legal!parent!/!guardian!! Parent/Guardian’s!Full!Name!!of_____________________________________,!who!is!voluntarily!participating!with!Troop!____________,!! Participant’s!Full!Name!! ! ! ! ! ! ! ! ! #!BSA,!Pikes!Peak!Council,!Ute!District!Troops!and!Crews!2014!Fall!Camporee,!at!Camp!Falcon,!Fort!Carson,!CO.!!$Adult$Section:$(for$participants$who$are$18$years$of$age$or$older)$$I,!_____________________________________,!am!voluntarily!participating!with!Troop!_________,!at!the!! Participant’s!Full!Name!#!BSA,!Pikes!Peak!Council,!Ute!Troops,!Teams!and!Crews!2014!Fall!Camporee,!at!Camp!Falcon,!Fort!Carson,!CO.!RELEASE,!COVENANT!&!HOLD!HARMLESS!AGREEMENT!KNOW!ALL!MEN!BY!THESE!PRESENTS!that!in!exchange!for!the!permission!of!Camp!Falcon!to!use!its!properties!do!herewith!release!Camp!Falcon!from!liability!for!any!and!all!injuries!which!my!son!may!sustain!during!the!period!of!time!that!he!is!upon!and!using!its!property,!whether!any!such!injuries!may!be!from!negligence!of!breach!of!warranty!of!Camp!Falcon!or!any!other!party!or!person!who!may!cause!him!injury.!This!prospective!release!is!effective!as!to!Camp!Falcon!any!agent,!employee,!or!other!person!for!whose!conduct!Camp!Falcon!may!be!liable.!This!Release!is!a!release!of!any!and!all!claims,!demands,!damages,!actions,!causes!of!action,!or!suits!at!law!or!in!equity!of!whatsoever!kind!or!nature,!for!or!because!of!any!matter!or!thing!done,!omitted,!or!suffered!to!be!done!by!Camp!Falcon!prior!to!and!during!the!period!of!time!my!child!is!using!its!property.!!I!agree!to!follow!the!rules!established!by!the!instructors,!safety!officers,!and!staff,!and!to!exercise!reasonable!care!while!participating!in!the!classes!and!exercise.!I!understand!that!if!I!fail!to!follow!any!instructions!issued!by!these!personnel,!or!if!I!fail!to!exercise!reasonable!care,!I!can!be!administratively!removed!from!the!classes!and!exercise.!!In!addition!to!the!above!described!Release,!I!herewith!and!hereby!covenant!not!to!cause!any!litigation!to!be!filed!against!Camp!Falcon!personnel!and!to!hold!them!harmless!and!indemnify!each!for!any!litigation!which!is!filed!against!it,!or!claims!made!against!it!which!litigation!or!claims!are!based!on!my!conduct.!!FURTHER,!Releasor!sayeth!naught.!Dated!this!_______day!of!_____________!2014!! ! ! ! ! ! !!!!!!Date!! !!!!!!!!!!!Month!!SIGNATURE!(Parent/Guardian)!________________________________________________________________!!!Name!(please!print)!_________________________________________________________________________!!Address!_________________________________!City__________________________,!State__________,!!ZIP!Code___________,!USA! Home!Phone!______________________Work!Phone!______________________!

Colorado!State!Law!Requires!that!all!information!must!be!complete!and!legible!before!users!may!enter!the!field.!

Required$for$Each$Participant$$

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This form is recommended for unit use to obtain approval and consent for Tiger Cubs, Cub Scouts, Webelos Scouts, Boy Scouts, Varsity Scouts, Venturers, and guests (if applicable) under 21 years of age to participate in a den, pack, team, troop, or crew trip, expedition, or activity. This form is required for use with flying plans and should be attached to the flying plan application. It is recommended that parents keep a copy of the form and contact the tour leader in the event of any questions or in case emergency contact is needed. Additional copies of this form along with the Guide to Safe Scouting are available for download from Scouting Safely at www.scouting.org/forms.

Se recomienda que la unidad use este formulario para obtener la aprobación y consentimiento para los Tiger Cubs, Cub Scouts, Webelos Scouts, Boy Scouts, Varsity Scouts, Venturers e invitados (si es que aplica) menores de 21 años que participen en un viaje, expedición o actividad del den, pack, equipo, tropa o grupo. Este formulario es obligatorio junto con los permisos de vuelo y deben adjuntarse a la solicitud de permiso de vuelo. Se recomienda que los padres de familia guarden una copia del formulario y se pongan en contacto con el líder de la excursión si es que tienen alguna pregunta o en caso de que se necesite un contacto de emergencia. Las copias adicionales de este formulario junto con la Guía para un Scouting seguro se encuentran disponibles para descargar desde Scouting Safely en www.scouting.org/forms.

ACTIVITY CONSENT FORM AND APPROVAL BY PARENTS OR LEGAL GUARDIANFORMULARIO DE CONSENTIMIENTO Y APROBACIÓN DE ACTIVIDAD POR PARTE

DE LOS PADRES DE FAMILIA O TUTORES

HOLD HARMLESS AGREEMENTI understand that participation in Scouting activities involves a certain degree of risk and can be physically, mentally, and emotionally demanding. I have carefully considered the risk involved and have given consent for myself or my child to participate in this activity. I also understand that participation in this 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.

ACUERDO DE INDEMNIZACIÓN Y EXONERACIÓN DE RESPONSABILIDADEntiendo que la participación en actividades Scouting implica un cierto grado de riesgo y que pueden ser física, mental y emocionalmente agotadoras. He considerado cuidadosamente el riesgo involucrado y doy mi consentimiento para mi mismo o mi hijo para participar en la actividad. Entiendo que la participación en la actividad es completamente voluntaria y requiere que los participantes se acaten a las reglas y estándares de conducta pertinentes. Libero a Boy Scouts of America, al concilio local, a los coordinadores de la actividad y a todos los empleados, voluntarios, partes relacionadas u otras organizaciones asociadas con la actividad de cualquiera y todas las demandas o responsabilidades que surjan de esta participación.

En caso de una emergencia que tenga que ver con mi hijo, sé que se harán todos los esfuerzos necesarios para contactarme. En caso de que no me contacten, autorizo al proveedor médico seleccionado por el líder adulto encargado, de asegurarse de que se le ofrezca a mi hijo el tratamiento adecuado, incluyendo hospitalización, anestesia, cirugía o inyecciones de medicamento. Los proveedores médicos están autorizados para informar al adulto encargado los hallazgos de la exploración física, los resultados de pruebas y el tratamiento otorgado con el propósito de una evaluación médica del participante, seguimiento y comunicación con los padres o tutores del participante y/o la determinación de la capacidad del participante para continuar en las actividades del programa.

______________________________________________________ _____ _____________________________________________________ Birth date (month/day/year) ____/____/____ Age during activity ________ First name of participant Middle initial Last name Fecha de nacimiento (día/mes/año) Edad al momento de realizar Nombre del participante Inicial del sugundo nombre Apellido la actividad

____________________________________________________________________________________________________________________________________________________________________________________ Address Domicilio

City ____________________________________________________________________________________ State __________________________________________________________ Zip _____________________Ciudad Estado Código postal

Has approval to participate in (Name of activity, orientation flight, outing trip, etc.) __________________________________________________________________________________________________________________Tiene la aprobación para participar en (Nombre de la actividad, vuelo de orientación, excursión, etc.)

From ______________ to ______________ Without restrictions Special considerations or restrictions:De (Date) a (Date) Sin restricciones Consideraciones o restricciones especiales: (fecha) (fecha)

______________________________________________________________________________________________________________________________________________________ ________________________ Participant’s signature Date Firma del participante Fecha

______________________________________________________ __________________________________________________________________________________________

__________________________________________________________________________________________

________________________ Parent/guardian printed name Parent/guardian signature Date Nombre con letra de molde del padre de familia/tutor Firma del padre de familia/tutor Fecha

______________________________________________________ ______________________________________________________________________________________________________________________ Area code and telephone number (best contact and emergency contact) Email (for use in sharing more details about the trip or activity) Código de área y número telefónico (primer contacto y contacto de emergencia) Correo electrónico (para más detalles sobre el viaje o actividad)

Contact the adult tour leader with any questions: Póngase en contacto con el líder adulto de la excursión si es que tiene preguntas:

Name ___________________________________________________________________ Phone ___________________________ Email ________________________________________________________________Nombre Teléfono Correo electrónico

680-673 2012 Printing

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GUIDE TO TOUR PLANNING PRINCIPLES

ACTIVITY STANDARDS Where swimming or boating is included in the program, Safe Swim Defense and/or Safety Afloat are to be followed. If climbing and rappelling are included, then Climb On Safely must be followed. At least one person must be current in CPR/AED from any recognized agency to meet Safety Afloat and Climb On Safely guidelines. At least one adult on a pack overnighter must have completed Basic Adult Leader Outdoor Orientation (BALOO). At least one adult must have completed Planning and Preparing for Hazardous Weather training for all tours and activities. Basic First Aid is recommended for all tours, and Wilderness First Aid is recommended for all backcountry tours. It is also recommended to carry the Wilderness Use Policy and follow the principles of Leave No Trace. UNAUTHORIZED AND RESTRICTED ACTIVITIES The BSA’s general liability policy provides coverage for bodily injury or property damage that is made and arises out of an official Scouting activity as defined by the Guide to Safe Scouting. Volunteers, units, chartered organizations, and local councils that engage in unauthorized activities are jeopardizing their insurance coverage. PLEASE DO NOT PUT YOURSELF AT RISK. INSURANCE All vehicles MUST be covered by a liability and property damage insurance policy. The amount of this coverage must meet or exceed the insurance requirement of the state in which the vehicle is licensed and comply with or exceed the requirements of the country of destination for travel outside the United States. It is recommended, however, that coverage limits are at least $100,000 combined single limit. Any vehicle designed to carry 10 or more passengers is required to have limits of $500,000 combined single limit. In the case of rented vehicles, the requirement of coverage limits can be met by combining the limits of personal coverage carried by the driver with coverage carried by the owner of the rented vehicle. TRANSPORTATION GUIDELINES 1. You will enforce reasonable travel speed in accordance with state and local laws in all motor vehicles. 2. If by motor vehicle:

a. Driver qualifications: All Boy Scout adult drivers and all Venturing adult drivers must have a valid driver’s license. Youth member exception: When traveling to an area, regional, or national Boy Scout event/activity or any Venturing event/activity under the leadership of an adult (21 or older) tour leader, a youth member at least 16 years of age may be a driver, subject to the following conditions: (1) The person has six months’ driving experience as a licensed driver (time on a learner’s permit or equivalent is not to be counted); (2) there is no record of accidents or moving violations; (3) parental permission has been granted to the leader, driver, and riders.

b. If the vehicle to be used is designed to carry more than 15 people (including the driver), the driver must have a commercial driver’s license (CDL). In some states (for example, California), this guideline applies to 10 or more people.

c. Driving time is limited to a maximum of 10 hours in one 24-hour period and must be interrupted by frequent rest, food, and recreational stops.

d. Safety belts are provided and must be used by all passengers and the driver. Exception to this guideline: a school or commercial bus, when not required by law.

e. Passengers will ride only in the cab if trucks are used. YOUR PLEDGE OF PERFORMANCE 1. We will submit changes to notify the local council in the event our itinerary or activity changes. 2. We will plan our activities by and adhere to the policies contained in the Guide to Safe Scouting and the Sweet Sixteen of BSA Safety. 3. We will use Safe Swim Defense in any swimming activity, Safety Afloat in all watercraft activity, and Climb On Safely for climbing

activity. 4. We agree to enforce reasonable travel speed (in accordance with national, state, and local laws) and use only vehicles that are in safe

mechanical condition. 5. We will apply for a fire permit from local authorities in all areas where it is required. 6. We will be certain that fires are attended to at all times and we are adhering to all fire bans. 7. We will, at all times, be a credit to the Boy Scouts of America and will not tolerate rowdy behavior and poor conduct, keeping a

constant check on all members of our group. 8. We will maintain high standards of personal cleanliness and orderliness and will operate a clean and sanitary camp, leaving it in a

better condition than we found it. 9. We will not litter or bury any trash, garbage, or tin cans. All rubbish that cannot be burned will be placed in a tote-litter bag and taken to

the nearest recognized trash disposal or all the way home, if necessary. 10. We will not deface natural or man-made objects. 11. We will respect the property of others and will not trespass. 12. We will not cut standing trees or shrubs without specific permission from the landowner or manager. 13. We will, in case of backcountry expedition, read and abide by the Wilderness Use Policy of the BSA. 14. We will notify, in case of emergency, our local council Scout executive, our parents, and our single point of contact. 15. If more than one vehicle is used to transport our group, we will establish rendezvous points at the start of each day and not attempt to

have drivers closely follow the group vehicle in front of them. 16. Identify and agree to follow all land-use policies (public and private) in effect for the location of the tour.

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TOUR AND ACTIVITY PLANDate __________________________________________________________________________

Pack Troop/team Crew/Ship Contingent unit/crew Unit No. _________ Chartered organization __________________________________________Council name/No. ________________________________________________/_______________District _________________________________________________________________________Description of tour or activity ______________________________________________________From (city and state) ______________________________to _____________________________Dates _________________________ to ________________________ Total days ____________Itinerary: It is required that the following information be provided for each day of the tour. (Note: Speed or excessive daily mileage increases the possibility of accidents.) Attach an addi-tional page if more space is required. Include detailed information on campsites, routes, and float plans, and include maps for wilderness travel as required by the local council.

DateTravel

Mileage Overnight stopping place (Check if reservations are cleared.)From To

Type of trip: Day trip Short-term camp (less than 72 hours) Other (OA Weekend, etc.) _________________________________ Long-term camp (longer than 72 hours) High-adventure activities High-adventure base____________________

Party will consist of (number):____ Youth—male ____ Youth—female____ Adults—male ____ Adults—female

Party will travel by (check all that apply): Car Bus Train Plane Van Boat Other ______________________________________________________________

Leadership and Youth Protection Training: Boy Scouts of America policy requires at least two adult leaders on all BSA activities. Coed Venturing crews must have both male and female leaders older than 21 for overnight activities. All registered adults must have completed BSA Youth Protection training. At least one registered adult who has completed BSA Youth Protection training must be present at all events and activities. Youth Protection training is valid for two years from the date completed. Adult leader responsible for this group (must be at least 21 years old):

Name ____________________________________ Age _______ Scouting position _________________________________________________

Address __________________________________________________________________________________ Member No. ________________

City __________________________________________________________ State _______________ Zip code ___________________________

Phone _______________________________ Email ___________________________________ Youth Protection training date ______________

Assistant adult leader name(s) (minimum age 18, or 21 for Venturing crews):

Name ____________________________________ Age _______ Scouting position _________________________________________________

Address __________________________________________________________________________________ Member No. ________________

City __________________________________________________________ State _______________ Zip code ___________________________

Phone _______________________________ Email ___________________________________ Youth Protection training date ______________Attach a list with additional names and information as outlined above.

Our travel equipment will include a first-aid kit and a roadside emergency kit.

The group will have in possession an Annual Health and Medical Record for every participant.

We certify that appropriate planning has been conducted using the Sweet 16 of BSA Safety, qualified and trained supervision is in place, permissions are secured, health records have been reviewed, and adult leaders have read and are in possession of a current copy of Guide to Safe Scouting and other appropriate resources. Any items needing attention will be resolved before the tour or activity date.

Signature: Committee chair or chartered organization representative Signature: Adult leader

Unit single point of contact (not on tour)

Name ____________________________________Phone __________________Email_________________________________________________

For office use

Tour and activity plan No. ____________Date received _______________________Date reviewed ______________________

Council stamp/signatures

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2

Tour involves: Swimming Boating Climbing Orienta hts (attach Flying Plan required) Wilderness or backcountry (must carry Wilderness Use Policy and follow principles of Leave No Trace) Shooting Other (specify) Activity Standards: Where swimming or boating is included in the program, Safe Swim Defense and/or Safety A oat are to be followed. If climbing/rappelling is included, then Climb On Safely must be followed. At least one person must be current in CPR/AED from any recognized agency to meet Safety A at and Climb On Safely guidelines. At least one adult on a pack overnighter must have completed Basic Adult Leader Outdoor Orientation (BALOO). At least one adult must have completed Planning and Preparing for Hazardous Weather training for all tours and activities. Trek Safely and Basic First Aid are recommended for all tours, and Wilderness First Aid is recommended for all backcountry tours.

Expiration date of commitment card/training (two years from completion date)

Name Age Youth Protection

Planning and Preparing

for Hazardous Weather

BALOO(no

expiration)

Climb On Safely Safe Swim Defense

Safety A at

Name Age CPR Cer ation/Agency CPR Expiration Date

First-Aid Cer ation/Agency First Aid Expiration Date

Name Age NRA Instructor and/or RSO

No. _______ R Shotgun Pistol (Venturing only) Range Safety O cer Muzzle-loading r Muzzle-loading shotgun

No. _______ R Shotgun Pistol (Venturing only) Range Safety O cer Muzzle-loading r Muzzle-loading shotgun

Unauthorized and Restricted Activities: The BSA’s general liability insurance policy provides coverage for bodily injury or property damage that arises out of an o cial Scouting activity as d ned by the Guide to Safe Scouting. Volunteers, units, chartered organizations, and local councils that engage in unauthorized activities are jeopardizing their insurance coverage. PLEASE DO NOT PUT YOURSELF AT RISK.INSURANCEAll vehicles MUST be covered by a liability and property damage insurance policy. The amount of this coverage must meet or exceed the insurance requirement of the state in which the vehicle is licensed and comply with or exceed the requirements of the country of destination for travel outside the United States. It is recommended, however, that coverage limits are a $100,000 combined single limit. Any vehicle designed to carry 10 or more passengers is required to have a $500,000 combined single limit. In the case of rented vehicles, the requirement of coverage limits can be met by combining the limits of personal coverage carried by the driver with coverage carried by the owner of the rented vehicle.

If the vehicle to be used is designed to carry more than 15 people (including the driver), the driver must have a valid commercial driver’s license (CDL). In some states (California, for example), this policy applies to drivers of vehicles designed to carry 10 or more people.

All vehicles used in travel outside the United States must carry a public liability and property damage liability insurance policy that complies with or exceeds the requirements of that country. Attach an additional page if more space is required.

Name ___________________________________________________________ CDL expires ___________________________________________

Name ___________________________________________________________ CDL expires ___________________________________________

680-014 2011 Printing Rev. 12/2011

MAKE MODEL YEAR

NUM

BER

OF

SAFE

TY B

ELTS

DRIVER/OWNER

VALID DRIVER’SLICENSE(Y or N)

LIABILITY INSURANCE COVERAGE

Combined Single Limit

Guide to Tour Planning Principles

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Part A: Informed Consent, Release Agreement, and Authorization

Full name: ________________________________________

DOB: ________________________________________

High-adventure base participants:Expedition/crew No.: _______________________________or staff position: ___________________________________

680-0012014 Printing

Complete this section for youth participants only:Adults Authorized to Take to and From Events:You must designate at least one adult. Please include a telephone number.

I understand that, if any information I/we have provided is found to be inaccurate, it may limit and/or eliminate the opportunity for participation in any event or activity. If I am participating at Philmont, Philmont Training Center, Northern Tier, Florida Sea Base, or the Summit Bechtel Reserve, I have also read and understand the supplemental risk advisories, including height and weight requirements and restrictions, and understand that the participant will not be allowed to participate in applicable high-adventure programs if those requirements are not met. The participant has permission to engage in all high-adventure activities described, except as specifically noted by me or the health-care provider. If the participant is under the age of 18, a parent or guardian’s signature is required.

Participant’s signature: ________________________________________________________________________________________ Date: ______________________________

Parent/guardian signature for youth: _____________________________________________________________________________ Date: ______________________________

(If participant is under the age of 18)

Second parent/guardian signature for youth: ______________________________________________________________________ Date: ______________________________

(If required; for example, California)

Name: ______________________________________________________

Telephone: __________________________________________________

Name: ______________________________________________________

Telephone: __________________________________________________

Adults NOT Authorized to Take Youth To and From Events: Name: ______________________________________________________

Telephone: __________________________________________________

Name: ______________________________________________________

Telephone: __________________________________________________

Informed Consent, Release Agreement, and AuthorizationI 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 your 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.

In case of an emergency involving me or my child, I understand that efforts will be made to contact the individual listed as the emergency contact person by the medical provider and/or adult leader. In the event that this person cannot be reached, permission is hereby given to the medical provider selected by the adult leader in charge to secure proper treatment, including hospitalization, anesthesia, surgery, or injections of medication for me or my child. Medical providers are authorized to disclose protected health information to the adult in charge, camp medical staff, camp management, 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.

(If applicable) 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 on this form 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, 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.

I also hereby assign and grant to the local council and the Boy Scouts of America, as well as their authorized representatives, the right and permission to use and publish the photographs/film/videotapes/electronic representations and/or sound recordings made of me or my child at all Scouting activities, and I hereby 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 liability from such use and publication. I further authorize the reproduction, sale, copyright, exhibit, broadcast, electronic storage, and/or distribution of said photographs/film/videotapes/electronic representations and/or sound recordings without limitation at the discretion of the BSA, and I specifically waive any right to any compensation I may have for any of the foregoing.

NOTE: Due to the nature of programs and activities, the Boy Scouts of America and local councils 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.

List participant restrictions, if any: None

________________________________________________________

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Pavilions 1 – 2 1 – C

hallenger Point 2 – Snow

mass M

ountain

Cam

psites 1 – 9 1 – Q

uandary 2 – M

issouri 3 – H

umbolt

4 – Mt. D

emocrat

5 – Um

compam

gre 6 – K

it Carson

7 – Crestone N

eedle 8 – Longs Peak 9 – Ellingw

ood

Mountain M

eadows G

roup Sites 1 – 5

1P – La Plata 2P – C

ulebra 3P – Shavano 4P – Elbert 5P – B

elford

2

1G

3

5

1

7

9

4

6

8

3G

2G

5G

4G

Port-a-johns

Parking Staff R

estrooms

Flag Poles

Fire Ring

1 2

Station Tents

Staff Dining

Medic Station

Cam

poree C

ampfire

Fire Extinguisher Training Station

Handicap Site

Staff Cam

ping

OFF LIM

ITS

(35)

(10) (10)

(20) (20)

(25) (20)

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