Today's Date
MM
DD
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Camp Type
Select One
Pow Wow 2023
Name
Are you over the age of 18?
If not, what is your legal guardian's name?
Birth Date:
MM
DD
YYYY
Age:
Sex:
Full Address:
Home Phone
(###)
###
####
Cell Phone
(###)
###
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Church Name:
Church Address
Church Phone
(###)
###
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Shirt Size
Select One
Youth S
Youth M
Youth L
Adult S
Adult M
Adult L
Adult XL
Adult 2XL
Adult 3XL
Adult 4XL
Name of Emergency Contact
Relationship to Participant
Emergency Contact Cell Phone
(###)
###
####
Emergency Contact Alt Phone
(###)
###
####
Name of Youth/Minor
Date of Birth of Youth/Minor
MM
DD
YYYY
Name of Custodial Parent/Guardian
I, above named Custodial Parent/Guardian, grant my consent to the West Texas & Plains District Royal Rangers and to its representatives including Royal Ranger Commanders, volunteer adult instructors, and others serving in these positions to provide my child, with appropriate backpacking equipment, and provide instruction as to their use and techniques. I further certify that I am a custodial parent with full parental rights or the legal guardian of this child. I understand that this document will be kept and maintained by West Texas & Plains District Royal Rangers or its representatives including, but not limited to, local outpost (church), Royal Ranger Commanders and other adult volunteer instructors. I further understand that only the original document will be accepted and that any modification of this form, except as instructed below, will deem the form invalid and will not be accepted by the local Outpost, West Texas & Plains District Royal Rangers, Royal Ranger Commanders and other volunteer adult Instructors. I further understand that this document will remain in effect for the period listed below, unless revoked. This “Permission to participate in the Pow Wow 2023 Event” may be revoked at any time by notifying your local outpost (church) and upon notification, the original document will be returned. I do further agree to indemnify and save harmless the West Texas & Plains District Royal Rangers, the local Outpost (church), all Royal Ranger Commanders, members, employees, volunteers thereof, and landowners from all suits or actions brought for, or on account of, any injuries or damages received or sustained by any person or persons by or from the consequences of any negligence or any act or omission of the above named minor occurring during the course of said instruction. MEDICAL CONSENT The signature of a parent or legal guardian is required in order to attend Pow Wow 2023. A parent or guardian must sign this form, indicating permission to authorize the provisions of emergency treatment for the MINOR who may become ill or injured at a church event. WITH MY SIGNATURE BELOW I, THE LEGAL GUARDIAN OF THE ABOVE LISTED CHILD, DO HEREBY GIVE MY CONSENT, TO THE ADMINISTRATION OF ANY TREATMENT DEEMED NECESSARY BY LICENSED PHYSICIANS, DENTISTS, OR EMERGENCY PERSONNEL. Inclusive period: Starting September 8, 2023, and ending September 10, 2023. By typing your name below, you are signing this Agreement electronically. You agree your electronic signature is the legal equivalent of your manual signature on this Agreement.
*
Date
MM
DD
YYYY
Primary Doctor's Name
Primary Doctor's Phone
(###)
###
####
Is Child in Good Health?
If No, Please Explain:
Allergies:
If none, leave blank
Physical Impairments
Epilepsy, Heart Conditions, etc.
If none, leave blank
Specify any medications that must be administered or supervised
If none, leave blank
Date of last Tetanus shot
Any Special Instructions for Care?
If none, leave blank
