BOY SCOUTS OF AMERICA TROOP 164
ACTIVITY INFORMATION AND RELEASE FORM
[Winter Camp, Camp Pupakea 26-31 Dec 11]
Troop 164 will attend Winter Camp at Camp Pupakea from 26-31 Dec 2011. The Troop will assemble at Rec 6 at
11:00 and leave at 11:15 Parents need to pick up their scout at Camp Pupakea by 11:00 31 Dec. There is a cost of
$165 for this event. This event is restricted to only those active Scouts who have a current annual medical update
on file and who are not more than two months behind in paying their program fees. This permission slip must be
returned by 11/17/11 to Dan or Daniel Hulsebosch. The attached Code of Conduct must be signed by the Scout and
his parent or guardian to be eligible to attend.
RETAIN THIS SECTION FOR YOUR RECORDS
DETACH AND RETURN RELEASE FORM
*************** RELEASE FORM***************
I/We_____________________________ _ residing at ______________________and the lawful parent/guardian of
___________________ in consideration of the permission extended to me and/or my child(ren) by Troop 164 BSA,
through it's officers and agents, to participate in the annual [Winter Camp, 26-31 Dec 11], do hereby remiss,
release, and forever discharge Troop 164, Aloha Council, and all of it's officers, agents, and employees, acting
officially or otherwise, from any and all claims, demands, actions, or causes of action on account of death, or
injury, or whatever kind of nature, which may occur to either myself or any of my/our above named child(ren)
during said activity, as well as activities incident thereto. [We further consent in advance for named above, to
whatever X- ray examination, anesthesia, medical, or surgical diagnostic procedure or treatment considered
necessary in the best judgment of attending medical officer. It is understood that, in the event of injury or illness
suffered by my child(ren) occurring in my/our absence, reasonable efforts will be made to reach me/us prior to
performing such procedures, but that my/our non-availability will not preclude the performance of those procedures
deemed necessary by the aforesaid medical personnel. The signature of the parent/guardian also indicates their
support of the Troop's Leader/Scout/Parent Agreement, which are important guidelines for establishing a SAFE
environment. Also, the attached Code of Conduct must be signed by the Scout and parent or guardian to be eligible
My Scout will participate in activities on: (Check All That Apply) __X__ Friday __X__ Saturday _X___ Sunday
My Scout needs transportation: BOTH WAYS_____ GOING OUT ONLY_____ RETURNING ONLY_____.
BOY SCOUTS OF AMERICA
CODE OF CONDUCT AND STATEMENT OF UNDERSTANDING
Statement of Understanding: All youth participants and the parents or guardians are asked to sign the Code of Conduct and Statement of
Understanding as a condition of participation with the further understanding that serious misconduct or infraction of the code may result in
expulsion. Ultimately, we want each participant to be responsible for their own behavior, and only when necessary will the procedure be
invoked to send a Scout home from the event.
All youth and adult participants are expected to abide by the Code of Conduct as follows:
1. The event adult leaders (Advisors and Assistants) are responsible for the supervision of the Scouts participating in respect to maintaining
discipline and security.
2. The Scout Oath and Law will be my guide throughout the event.
3. I will set a good example by keeping myself neatly dressed and presentable: (The official Scout uniform or activity uniform when
4. I will attend all scheduled programs and participate as required in cooperation with other members and leadership.
5. In consideration of other event participants, I agree to follow the lights out and bedtime schedule of the event. I will not bring portable
electronic equipment of any kind to any event.
6. I will be responsible for keeping my tent and personal gear labeled, clean, and neat. I will observe the Outdoor Code and will do my share
to prevent littering.
7. It is clearly understood that the purchase, possession or consumption of alcoholic beverages or illegal drugs by any Scout is prohibited.
This standard shall apply to all participants, both youth and adult.
8. Serious and/or repetitive behavior violations by youth including use of tobacco, cheating, stealing, dishonesty, swearing, fighting, cursing,
unsafe use of propane, knives, butane lighters, (no Zippo styles allowed) incorrect use of fires, stoves, and lantern, and possession of
pornographic material may result in expulsion from the event or serious disciplinary actions and loss of privileges.
9. I agree that gambling of any form is prohibited.
10. Possession or detonation if fireworks are prohibited.
11. I will demonstrate respect for troop property and be personally responsible for cleanliness and any loss, breakage, or vandalism of
12. Neither the event leaders, nor Troop 164 will be responsible for loss, breakage or theft of personal items. I will label all my personal
items and check items of value at the direction of troop leaders. Theft will be grounds for expulsion.
13. While participating in this event, all Scouts and leaders will obey the safety rules and instructions of all supervisors and unit leaders.
14. Adult leaders and youths are prohibited from having firearms and weapons in their possession in accordance with BSA regulations and
local and state laws.
15. Advisers and Assistants will be guided by the Scout Oath and Scout Law, and will obey all local and state laws.
16. Advisers and Assistants must receive Youth Protection Training and follow the guidelines therein.
17. Hazing has no place in Scouting, nor does running the gauntlet, belt lines, or similar physical punishment. Leaders and older Scouts must
prevent all Scouts from being "initiated" into the group with a hazing activity.
18. Adult leaders should have the good judgment to avoid trading souvenirs or patches with a child or youth member in Scouting. Youth
members may trade with youth members. Adult leaders must trade only with other adults 18 years of age or older.
19. Adult leaders and youth leaders must instruct youth and leaders to avoid confrontation with groups, demonstrations, or hecklers and
assume a passive reaction to name calling from individuals or groups. Remove the Scout group from the area of potential conflict
20. Serious violations of this code may result in expulsion at the participant's own expense from the event. All decisions will be final.
I certify that I have read the Statement of Understanding and agree to abide by the conditions in the
Code of Conduct as a participant in Troop 164 events.
Signature of Participant
Signature of Parents or
(if participant is under 21 years of age)
Signature of Event
I can help drive #_2__ Scouts (include yours): BOTH WAYS_____ GOING OUT ONLY_____ RETURNING ONLY
I can assist in supervising this event: YES__X___NO_____. Days I can supervise are_____________________
Phone number where I can be reached during this activity period is_________________.
My son(s) is/are in the ___NINJA__________________Patrol.
Signature of parent/guardian______________________________________________