Return By:	Sunday, June 15

Activity:	Shooting Outing: Camping at Camp Trask

Adult Leader Contact:

Name:	Edwin Pribadi	Phone:	909-348-3080	email:	c_dmail@yahoo.com

Northminster Presbyterian Church	Friday, 6/20/2025 6:00p	CVS Diamond Bar	Sunday, 6/22/2025 Approx 10:00a
Leaving/ Meeting at	Date/Time	Returning To	Date/Time

Fees:

Activity Fee	Transp. Fee	Food	Each	Qty	Each	Total
Scouts:	$60	+	---	+	$18	=	$96	Scouts:	x	$78	=	$0
Adults:	$60	+	---	+	$20	=	$98	Adults:	x	$80	=	$0
Total	$0

Notes:	Dress in Class-A uniform. We travel to/from in uniform. Bring personal gear and 10 Essentials. Bring chairs and EZ-Up. Send ZELLE payment to: troop777zelle@gmail.com

(Provide all information)

– ALL PARTICIPANTS –

Participant Name #1	Patrol	Birth Date (MM/DD/YYYY)	Age During Activity
Participant Name #2	Patrol	Birth Date (MM/DD/YYYY)	Age During Activity
CA
Address	City	State	ZIP
͏ Needs Ride
Has approval to participate in the above stated activity
͏ Without Restrictions	͏ Special Considerations or Restrictions:

– EMERGENCY CONTACT –

Printed Name	Phone Number (With Area Code)	Email

– ADULT PARTICIPANTS –

TRAINING INFORMATION	TRANSPORTATION
BSA ID#:	͏	to and from
year & make of vehicle	driver’s license #	Total # of passengers
YPT DATE:	͏	to only
AB506 DATE	͏	from only	each person	each accident	property damage
LIVESCAN DATE:	͏	͏Insurance meets or exceeds minimum state requirements

HOLD HARMLESS AGREEMENT

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.

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. §§160.103, 164.501, etc. seq., as amended from time to time, includes examination findings, test results, and treatment provided for purposes of medical evaluation of the participant, follow-up and communication with the participant’s parents or guardian, and/or determination of the participant’s ability to continue in the program activities.

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

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 and counsel your child to comply with those restrictions.