{"id":119,"date":"2021-11-05T22:52:48","date_gmt":"2021-11-05T22:52:48","guid":{"rendered":"https:\/\/pack55okc.org\/?page_id=119"},"modified":"2024-09-12T18:42:48","modified_gmt":"2024-09-12T18:42:48","slug":"activity-consent-form","status":"publish","type":"page","link":"https:\/\/pack55okc.org\/?page_id=119","title":{"rendered":"Activity Consent Form"},"content":{"rendered":"<p><span style=\"font-weight: 400;\"><div class=\"wpforms-container wpforms-container-full wpforms-render-modern\" id=\"wpforms-216\"><form id=\"wpforms-form-216\" class=\"wpforms-validate wpforms-form wpforms-ajax-form\" data-formid=\"216\" method=\"post\" enctype=\"multipart\/form-data\" action=\"\/index.php?rest_route=%2Fwp%2Fv2%2Fpages%2F119\" data-token=\"f86559fc70a7f07b5bd12ada54b7d8b1\" data-token-time=\"1777988031\"><div class=\"wpforms-head-container\"><div class=\"wpforms-description\">The recommended use of this form is for the consent and approval for Cub Scouts, Boy Scouts, Varsity Scouts, Venturers, and guests to participate in a trip, expedition, or activity. It is required for use with flying plans.<\/div><\/div><noscript class=\"wpforms-error-noscript\">Please enable JavaScript in your browser to complete this form.<\/noscript><div class=\"wpforms-hidden\" id=\"wpforms-error-noscript\">Please enable JavaScript in your browser to complete this form.<\/div><div class=\"wpforms-field-container\"><div id=\"wpforms-216-field_32-container\" class=\"wpforms-field wpforms-field-name\" data-field-id=\"32\"><label class=\"wpforms-field-label\" for=\"wpforms-216-field_32\">ACTIVITY CONSENT FORM AND APPROVAL BY PARENTS OR LEGAL GUARDIAN: <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-216-field_32\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][32]\" placeholder=\"{Parent_Name}\" aria-errormessage=\"wpforms-216-field_32-error\" required><\/div><div id=\"wpforms-216-field_7-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"7\"><label class=\"wpforms-field-label\" for=\"wpforms-216-field_7\">First name of participant: <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-216-field_7\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][7]\" placeholder=\"{Participant_FirstName}\" aria-errormessage=\"wpforms-216-field_7-error\" required><\/div><div id=\"wpforms-216-field_8-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"8\"><label class=\"wpforms-field-label\" for=\"wpforms-216-field_8\">Middle initial: <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-216-field_8\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][8]\" placeholder=\"{Participant_MI}\" aria-errormessage=\"wpforms-216-field_8-error\" required><\/div><div id=\"wpforms-216-field_9-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"9\"><label class=\"wpforms-field-label\" for=\"wpforms-216-field_9\">Last name: <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-216-field_9\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][9]\" placeholder=\"{Participant_LastName}\" aria-errormessage=\"wpforms-216-field_9-error\" required><\/div><div id=\"wpforms-216-field_11-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"11\"><label class=\"wpforms-field-label\" for=\"wpforms-216-field_11\">Birth date:  <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-216-field_11\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][11]\" placeholder=\"{Participant_DOB}\" aria-errormessage=\"wpforms-216-field_11-error\" required><\/div><div id=\"wpforms-216-field_12-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"12\"><label class=\"wpforms-field-label\" for=\"wpforms-216-field_12\">Age during activity:  <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-216-field_12\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][12]\" placeholder=\"{Participant_Age}\" aria-errormessage=\"wpforms-216-field_12-error\" required><\/div><div id=\"wpforms-216-field_15-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"15\"><label class=\"wpforms-field-label\" for=\"wpforms-216-field_15\">Address: <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-216-field_15\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][15]\" placeholder=\"{Participant_Street_Address}\" aria-errormessage=\"wpforms-216-field_15-error\" required><\/div><div id=\"wpforms-216-field_16-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"16\"><label class=\"wpforms-field-label\" for=\"wpforms-216-field_16\">City: <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-216-field_16\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][16]\" placeholder=\"{Participant_City} \" aria-errormessage=\"wpforms-216-field_16-error\" required><\/div><div id=\"wpforms-216-field_17-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"17\"><label class=\"wpforms-field-label\" for=\"wpforms-216-field_17\">State: <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-216-field_17\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][17]\" placeholder=\"{Participant_State} \" aria-errormessage=\"wpforms-216-field_17-error\" required><\/div><div id=\"wpforms-216-field_18-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"18\"><label class=\"wpforms-field-label\" for=\"wpforms-216-field_18\">Zip: <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-216-field_18\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][18]\" placeholder=\"{Participant_Zip}\" aria-errormessage=\"wpforms-216-field_18-error\" required><\/div><div id=\"wpforms-216-field_19-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"19\"><label class=\"wpforms-field-label\" for=\"wpforms-216-field_19\">Name of activity, orientation flight, outing trip, etc that the participant is approved to participate in: <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-216-field_19\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][19]\" placeholder=\"{Activity_Name}\" aria-errormessage=\"wpforms-216-field_19-error\" required><\/div><div id=\"wpforms-216-field_20-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"20\"><label class=\"wpforms-field-label\" for=\"wpforms-216-field_20\">Date(s) activity is to be started\/ completed:  <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-216-field_20\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][20]\" placeholder=\"{Activity_Dates}\" aria-errormessage=\"wpforms-216-field_20-error\" required><\/div><div id=\"wpforms-216-field_37-container\" class=\"wpforms-field wpforms-field-content\" data-field-id=\"37\"><div id=\"wpforms-216-field_37\" class=\"wpforms-field-medium wpforms-field-row\" aria-errormessage=\"wpforms-216-field_37-error\"><h1><strong>INFORMED CONSENT, RELEASE AGREEMENT, AND AUTHORIZATION<\/strong><\/h1>\n<p>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.<\/p>\n<p>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.<\/p>\n<ul>\n<li>\u00a7160.103, 164.501, etc. seq., as amended from time to time, includes examination findings, test results, and<\/li>\n<\/ul>\n<p>treatment provided for purposes of medical evaluation of the participant, follow-up and communication with the participant\u2019s parents or guardian, and\/or determination of the participant\u2019s ability to continue in the program activities.<\/p>\n<p>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.<\/p>\n<p>NOTE: 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. List any restrictions imposed on a child participant in connection with programs or activities below and counsel your child to comply with those restrictions.<\/p>\n<div class=\"wpforms-field-content-display-frontend-clear\"><\/div><\/div><\/div><div id=\"wpforms-216-field_23-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"23\"><label class=\"wpforms-field-label\" for=\"wpforms-216-field_23\">Restrictions: <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-216-field_23\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][23]\" placeholder=\"{Participant_Restrictions}\" aria-errormessage=\"wpforms-216-field_23-error\" aria-describedby=\"wpforms-216-field_23-description\" required><div id=\"wpforms-216-field_23-description\" class=\"wpforms-field-description\">If no restrictions, type \"None\"<\/div><\/div><div id=\"wpforms-216-field_25-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"25\"><label class=\"wpforms-field-label\" for=\"wpforms-216-field_25\">Parent\/guardian first &amp; last name:  <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-216-field_25\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][25]\" placeholder=\"{Parent_FirstLastName}\" aria-errormessage=\"wpforms-216-field_25-error\" required><\/div><div id=\"wpforms-216-field_26-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"26\"><label class=\"wpforms-field-label\" for=\"wpforms-216-field_26\">Phone number: <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-216-field_26\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][26]\" placeholder=\"{Parent_phone} \" aria-errormessage=\"wpforms-216-field_26-error\" required><\/div><div id=\"wpforms-216-field_28-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"28\"><label class=\"wpforms-field-label\" for=\"wpforms-216-field_28\">Emergency contact first &amp; last name:  <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-216-field_28\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][28]\" placeholder=\"{Emergency_Contact_FirstLastName}\" aria-errormessage=\"wpforms-216-field_28-error\" required><\/div><div id=\"wpforms-216-field_29-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"29\"><label class=\"wpforms-field-label\" for=\"wpforms-216-field_29\">Phone number:  <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-216-field_29\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][29]\" placeholder=\"{Emergency_Contact_phone}\" aria-errormessage=\"wpforms-216-field_29-error\" required><\/div><div id=\"wpforms-216-field_31-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"31\"><label class=\"wpforms-field-label\" for=\"wpforms-216-field_31\">Signed By:  <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-216-field_31\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][31]\" placeholder=\"{ESignature}\" aria-errormessage=\"wpforms-216-field_31-error\" required><\/div><div id=\"wpforms-216-field_34-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"34\"><label class=\"wpforms-field-label\" for=\"wpforms-216-field_34\">Signed On:  <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-216-field_34\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][34]\" placeholder=\"{Date}\" aria-errormessage=\"wpforms-216-field_34-error\" required><\/div><\/div><!-- .wpforms-field-container --><div class=\"wpforms-submit-container\" ><input type=\"hidden\" name=\"wpforms[id]\" value=\"216\"><input type=\"hidden\" name=\"page_title\" value=\"\"><input type=\"hidden\" name=\"page_url\" value=\"https:\/\/pack55okc.org\/index.php?rest_route=%2Fwp%2Fv2%2Fpages%2F119\"><button type=\"submit\" name=\"wpforms[submit]\" id=\"wpforms-submit-216\" class=\"wpforms-submit\" data-alt-text=\"Sending...\" data-submit-text=\"Submit\" aria-live=\"assertive\" value=\"wpforms-submit\">Submit<\/button><img loading=\"lazy\" decoding=\"async\" src=\"https:\/\/pack55okc.org\/wp-content\/plugins\/wpforms\/assets\/images\/submit-spin.svg\" class=\"wpforms-submit-spinner\" style=\"display: none;\" width=\"26\" height=\"26\" alt=\"Loading\"><\/div><\/form><\/div>  <!-- .wpforms-container --><\/span><\/p>\n<p>Contact the adult leaders with any questions<\/p>\n<p>Committee Chair : Dennis Byford<\/p>\n<p>Cubmaster: Cliff Holmon<\/p>\n<p>Outdoor Chair: Neil Crittenden<\/p>\n","protected":false},"excerpt":{"rendered":"<p>Contact the adult leaders with any questions Committee Chair : Dennis Byford Cubmaster: Cliff Holmon Outdoor Chair: Neil Crittenden<\/p>\n","protected":false},"author":2,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"footnotes":""},"class_list":["post-119","page","type-page","status-publish","hentry"],"jetpack_sharing_enabled":true,"_links":{"self":[{"href":"https:\/\/pack55okc.org\/index.php?rest_route=\/wp\/v2\/pages\/119","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/pack55okc.org\/index.php?rest_route=\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/pack55okc.org\/index.php?rest_route=\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/pack55okc.org\/index.php?rest_route=\/wp\/v2\/users\/2"}],"replies":[{"embeddable":true,"href":"https:\/\/pack55okc.org\/index.php?rest_route=%2Fwp%2Fv2%2Fcomments&post=119"}],"version-history":[{"count":5,"href":"https:\/\/pack55okc.org\/index.php?rest_route=\/wp\/v2\/pages\/119\/revisions"}],"predecessor-version":[{"id":282,"href":"https:\/\/pack55okc.org\/index.php?rest_route=\/wp\/v2\/pages\/119\/revisions\/282"}],"wp:attachment":[{"href":"https:\/\/pack55okc.org\/index.php?rest_route=%2Fwp%2Fv2%2Fmedia&parent=119"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}