BOY SCOUTS OF AMERICA SILICON VALLEY MONTEREY BAY COUNCIL - DISTRICT: COYOTE CREEK; UNIT (PACK/TROOP/CREW): 689 GIRL SCOUTS OF NORTHERN CALIFORNIA TROOP: 60964 ACTIVITY CONSENT FORM AND APPROVAL BY PARENTS OR LEGAL GUARDIAN

Field Trip Destination:

Date(s) of Field Trip:

Participant’s Name:

Participant’s Age: Last

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Middle

Address:

Phone: Number/Street

City

Zip

Father/Guardian Name:

Phone:

Mother/Guardian Name:

Phone:

EMERGENCY Contact: (If unable to reach parent)

Phone: Name / Relationship

Physician’s Name:

Phone:

Name of Medical Insurance Carrier:

Phone:

Policy Number:

Effective Date:

CAMPING TRIP RELEASE AND WAIVER OF LIABILITY AND INDEMNITY AGREEMENT By signing below, I give my consent to have my son/daughter 1.

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voluntarily attend this field trip. (Please fill in participant’s name) THE UNDERSIGNED HEREBY RELEASES, WAIVES, DISCHARGES AND COVENANTS NOT TO SUE BOY SCOUTS OF AMERICA, GIRL SCOUTS OF NORTHER CALIFORNIA AND LIEN DOAN TRUONG GIANG, their scout leaders, board members, and volunteers (herein referred to as “releasees”) from all liability to my son/daughter, the undersigned, their personal representative, assigns, heirs, and next of kin for any loss or damage, and any claim or demands therefore on the account of injury to the person or property of, or resulting in death of my son / daughter, while my son / daughter participates in the field trip or excursion, sponsored, planned and directed by LIEN DOAN TRUONG GIANG. THE UNDERSIGNED HEREBY AGREES TO INDEMNIFY AND SAVE AND HOLD HARMLESS the releasees and each of them from any loss, liability, damage or cost they may incur due to the participation of my son / daughter in the field trip or excursion, sponsored, planned and directed by LIEN DOAN TRUONG GIANG. THE UNDERSIGNED HEREBY ASSUMES FULL RESPONSIBILITY FOR THE RISK OF BODILY INJURY, DEATH OR PROPERTY DAMAGE while my son / daughter is participating in the field trip or excursion, sponsored, planned and directed by LIEN DOAN TRUONG GIANG and THE UNDERSIGNED further expressly agrees that the foregoing RELEASE, WAIVER AND INDEMNITY AGREEMENT is intended to be as broad and inclusive as is permitted by the law of the State of California and that if any portion thereof is held invalid, it is agreed that the balance shall, notwithstanding, continue in full legal force and effect

THE UNDERSIGNED HAS READ AND VOLUNTARILY SIGNS THIS RELEASE AND WAIVER OF LIABILITY AND INDEMNITY AGRREMENT, and further agrees that no oral representations, statements or inducements apart from the foregoing written agreement have been made. I HAVE READ AND UNDERSTAND THIS RELEASE Date: Signature of Parent or Guardian