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Biloxi Bay District
Pine Burr Area Council
Boy Scouts of America

(For Sea Scouts and guests under 21 years of age
participating in a Sea Scout ship trip or activity)

First name__________________________ Last name_____________________________

Address_______________________________________ Birthdate___________________

City____________________________ State_______ Zip code______________________

Parent's business phone_____________________ Home phone______________________

Sea Scout trip/activity_________________________________ Date(s)_______________

My son or daughter named above has my permission to participate in the named trip or activity under the supervision of the adult leaders in charge. The adult leaders in charge have my permission to act in their best judgement on my behalf in all circumstances of health, welfare, morale, and discipline regarding my son/daughter.

Waiver of Claims
In consideration of the benefits to be derived from participation in this trip or activity, any and all claims against the Boy Scouts of America or its local councils, Sea Scout ship, and chartered organization, or against the officers, employees, agents, or other representatives of any of them, or any other persons working under their direction or engaged in the conduct of their affairs, arising out of any accident, illness, injury, damage, or other loss or harm to/or incurred or suffered by the applicant named above or to his or her property, in connection with or incidental to the trip or activity, including preliminary training and travel, are hereby expressly waived by the applicant and the applicant's family or guardians.

Medical Release
In the event of illness or injury occurring to my son or daughter while involved in this trip or activity, I consent to X-ray examination, anesthesia, and/or medical or surgical diagnostic procedures or treatment considered necessary in the best judgement of the attending physician and performed by or under the supervision of a member of the medical staff of the hospital furnishing medical services. It is understood that in the event of a serious illness or injury, reasonable efforts to reach me will be attempted.

Parent/Guardian Signature______________________________ Date____________________

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