Hold Harmless Agree 12

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					           Boy Scouts of America • Troop and Crew 153 • Antioch, California
Scout or Child’s Name: _________________________________ Date of Birth: __________
Scout or Child’s Name: _________________________________ Date of Birth: __________
Scout or Child’s Name: _________________________________ Date of Birth: __________
I understand that participation in the Boy Scout of America (BSA) program and events offered through
Troop and Crew 153, involves a certain degree of risk.
In consideration of the benefits to be derived, and after carefully considering the risks involved, and in
view of the fact that the Boy Scouts of America is an organization in which membership is voluntary, and
having full confidence that reasonable precautions will be taken to ensure the safety and well-being of my
child(ren), I hereby give consent for my child to participate in the Boy Scouts of America, Mt.
Diablo-Silverado Council, Diablo Sunrise District, and Troop / Crew 153 meetings and activities.
The BSA program may involve (under limited volunteer, non-professional, adult supervision): meetings,
training sessions, fellowships, parades, special ceremonies, fund raising events, service projects; trans-
portation (including car, bus, truck, van, water ferries, airplane or train) to/from activities; camping in the
wilderness, wilderness survival, outdoor cooking, fire management, backpacking, hiking, horseback riding,
running, jumping, rock climbing, rope climbing, repelling, zip lines, spelunking, skating, skiing, snow
camping, snow shoeing, snowboarding, snowmobiling, sledding, cycling and mountain biking; encounters
with insects, reptiles and wildlife of all types; encounters with unusual or severe weather, lightning,
flooding, and climate conditions; swimming, diving, snorkeling, scuba, white water rafting, canoeing,
boating, small boat sailing, ocean-lake-river kayaking; the use of knives, axes, slingshots, axe throwing,
wood carving; and other high adventure and high risk outings, or events. Under the strict supervision at
BSA camps or NRA instruction facilities… Scouts may participate in the controlled use of archery
equipment, small caliber firearms, pistols, rifles and shotguns.               List all restricted activities:
________________________________________________________________ Initial _____ Initial _____
Note: All of the above activities will be supervised by adult volunteers and senior scouts. Volunteers
within Troop and Crew 153 have limited knowledge in first aid and CPR. Volunteers within the Troop or
Crew are not medical professionals, nor are they licensed, certified, registered, or qualified as life
guards or NRA or CPR instructors.
In doing so, and except in cases where gross negligence is clearly demonstrated, I hold-
harmless from civil liability the Boy Scouts of America, the adult uniform leadership and non-
uniform members of the Parent’s Committee of Troop and Crew 153, its chartering
organization, and any volunteer adult assisting in Troop and Crew 153 activities.
Photographs / Film / Video Tapes / Name’s on membership records and organizational forms: I
hereby assign and grant to the Boy Scouts of America (BSA), Troop and Crew 153 (unless otherwise
noted on the permission form for a specific activity), the right and permission to use and publish my child’s
and our names / photographs / film / video tapes / electric representations and/or sound recording made
of my child’s activities; in the Troop / Crew newsletter, troop records and forms, organizational charts,
publications, internet, website, and in any public newspaper or television broadcast; and hereby release
the BSA, the chartering organization, and troop and crew members from any and all liability for such use.
 List exceptions; or [ ] None: ___________________________________ Initial _____ Initial _____
This form must be signed by the parent(s) or guardian(s) having legal custody of the above youth(s), and will
remain in effect as long as the youth is a member or participant in Troop and Crew 153 programs. Rev 05-16-11

Name: _______________________ Signature: _____________________ Date: ________
Name: ______________________   Signature: _____________________ Date: ________

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