2014 MMSR CAMP RESERVATION Troop #: Council Name: Council Street Address: Council City, State and Zip:
WEEK One 6/22-28 Two 6/29-7/5 Three 7/6-12 Four 7/13-19 Five 7/20-26
Date Reservation Made: Name of Unit Registrar: Unit Street Address: Unit City, State and Zip: Phone 1: Phone 2: Email:
NUMBER OF ATTENDEES Adults: Out of Council: In Council: In Council/FOS goal met ***HIGH ADVENTURE HA Out of Council/In Council HA In Council/FOS goal met
**CAMPSITE PICK 3 (i.e., 1, 2, 3) Adams Arapahoe Arikera Cheyenne Crow Custer Dakota Gordon Lakota Lilliwaup Oglala at $100 Reno at $250 Sioux at $225 Sissiton at $200 Strauss Teton at $325 at $300
**We will do our best to accommodate your request, however we reserve the right to make changes at any time. *** Reminder: High Adventure fees are non-refundable.
Troop deposit of $250.00 (which is non-refundable) confirms reservation. Only confirmed reservations will guarantee a spot! Check #: Select the type of credit card you will be using: Visa Mastercard Discover Credit Card Number: Expiration Date: 3 Digit Code: Credit Card Street Address : Credit Card Zip Code:
Make checks payable to: Black Hills Area Council 144 North Street Rapid City, SD 57701
BLACK HILLS AREA COUNCIL Boy Scouts of America 144 North Street, Rapid City, SD 57701 P 605.342.2824 F 605.342.2826 www.BlackHillsAreaCouncil.com
Black Hills Area Council
Contact Person Week In Camp
Campsite
Number of Scouts SUNDAY
Boy Scouts of America
Phone
Troop __________ Number of Patrols
Number of Adults MONDAY
TUESDAY
WEDNESDAY
THRUSDAY
FRIDAY
SATURDAY
B R E A K F A S T
L U N C H
S U P P E R
If your Troop is choosing to purchase premium meals at $3.00 per person, per meal, please circle all of the premium dinners chosen.
MMSR PARENT FACT SHEET Medicine Mountain Scout Ranch FACT SHEET FOR TROOP # _________________ We are going to MMSR. We will meet at (location) ____________________________ We will leave at______________ (time), please be early. It is approximately a _____hour ride to camp. Meals are/aren’t provided. Make sure you also have everything packed that you are supposed to have. Double check for any medicine (give it to your Scoutmaster or Troop Health Officer). Triple check to make sure you have your medical form (signed by your doctor and parents/guardians). The “early bird” cost for the Merit Badge and Hawk programs at camp is $225, and this includes almost everything. You will want some extra money for Trading Post items, souvenirs, and to pay for some extra merit badge costs such as handicrafts’ basketry, and the shooting sports merit badges. Mail is delivered into camp once a day and a letter or postcard can take anywhere from two to five days to get to camp. A letter from home can be one of the greatest cures for homesickness and helps the Scout get down to work. The Camp address is: Scout’s Name, Troop # Medicine Mountain Scout Ranch 24201 Bobcat Road Custer, SD 57730 There is only one phone line into camp. Please call only in case of emergencies. Campers will not be available to come to the phone, but a message may be delivered. The phone number is: (605) 673-2790 There is plenty to do while at camp, so come prepared. Do written work early, read the merit badge books at home, start now on projects. If you have any questions please call Tony Antonini (Camp Director) at 605-877-2423 or email him at... tony.antonini@scouting.org.
Informed Consent Agreement for High Adventure Activities Participant’s Name
Council / Unit Number
I understand that participation in the High Adventure activity offered through the Black Hills Area Council, BSA during summer camp, involves a certain degree of risk that could result in injury or death. In consideration of the benefits to be derived and after carefully considering the risk 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 precautions will be taken to ensure the safety and well-being of my (son/daughter), I have given my consent to participate in MMSR High Adventure Activities during his/her stay at the Medicine Mountain Scout Ranch. Participants are going to take part in a “High Adventure” experience. While participating, they will undertake a wide variety of physical and mental challenges in an environment designed with safety in mind. For most of the time, they will be undertaking activity that is best described as “moderate exertion”. This is comparable to normal walking, golfing on foot, downhill skiing, raking leaves, waiting tables, fishing, calisthenics, hanging wallpaper, interior painting, or slow dancing. There will be some situations where, for a few minutes, participants will be engaged in “vigorous exertion”. This is comparable to slow jogging, speed-walking, tennis, swimming, cross-country skiing, shoveling snow, fast biking, mowing with a push mower, pruning trees, heavy gardening, overhead work, ice hockey drills, softball, laying bricks, hurried restaurant work, or climbing a ladder. If these types of activities are difficult, we would have you discuss any participation in the activity with a physician who knows the participants personal health history. If these are activities in which one regularly engages without difficulty, the individual should be fit for participation. Lastly, there are a few specific medical conditions about which participants should always seek advice from their physicians before engaging in said activities. If any of these apply to you, you must consult with a physician before participating. If you or your physician has any questions about these conditions or about “High Adventure” activities, feel free to contact us at (605) 673-2790: • Pregnancy (climbing harness can injure the uterus) • Kidney or Liver Transplant (climbing harness can injure the transplanted organ) • Healing Fracture or Joint Injury (you should be cleared by the treating physician) • Recent Surgery (you should be cleared by the treating physician) • Down Syndrome (participant should have an X-ray check for neck stability as per the recommendation of the Special Olympics)
I certify that this participant can meet the health and physical fitness requirement for the trip or activity. It is understood that in the event of a serious illness or injury, reasonable efforts to reach me will be made.
Parent or Guardian Signature
Telephone Number
Date
Scout Release Request Form Scouts desiring/needing to leave the camp prior to their unit’s departure, or not as part of the unit, must have a release signed by their parent or guardian and approved by the Scoutmaster. Scouts should normally only be permitted to leave accompanied by their parents. The form below should be used in handling theses exceptional cases. In an emergency, it may not be possible for a parent or guardian to sign the release. In this event, sufficient information must be recorded attesting to the telephone call or means or communication by which work arrived asking for the release of the Scout. This information should document the person from whom the call was received, verify telephone confirmation of the parent asking for release of the Scout, and give detailed reasons for the release. Request is made that Scout: Scout’s Home Address: Council:
Unit Number:
Is permitted to leave camp for the following reasons: Scout to leave, Date:
Time:
Method of Travel:
Accompanied By: In signing this request for releases, BSA and parents or guardians mutually acknowledge that there will be no refund of camp fee; that the Council health and accident insurance terminates with the Scout’s departure from the Scout Camp; the BSA or its representatives shall not be liable for any loss or injury to Scout’s person or property. Request made by: (Parent’s or guardian’s signature required except as noted for emergency departure requests). Parent or guardian signature: Address: Telephone:
(Home)
Request Made:
(Business)
(Date)
Approval Scoutmaster’s signature:
ON-SITE RELEASE Before leaving the Black Hills Area Council Camp, the Scoutmaster must receive approval from the Camp Director. SM Initials: Troop/unit #: Date: CD initials:
Date:
Special Dietary Request Form Date: Unit Number:
Council:
Campsite: To cut down on problems we are asking all troops that have boys or adult leaders who require special diets (whether for medical problems or religious reasons) to fill out this request form and turn it in to the Council on or by March 31st (with their final payments). Name of Camper with special dietary need: Camper’s Parent/Guardian: Parent/Guardian Phone Number: Medical Condition/Reason for special diet request:
SPECIAL REQUEST (Example: Low-sodium diet, no pork, etc.)
This is vital to cut down on confusion and serving problems. Without this information, delays may occur. We will be happy to do whatever is necessary to fulfill the special needs of the individuals. However, please use this option only if medically necessary or required by religion. Thank You. -Commissary Staff
Unit Members Medical Insurance Information Form All Units attending summer camp MUST PROVIDE PROOF of Unit Accident Insurance. (Proof would be a copy of your policy or a letter of insurance from your council.) CIRCLE ONE:
Insurance is for Unit
Unit Number:
- or -
Insurance is provided by Council
Council Name:
Policy Holder’s Name: Policy Holder’s Address: City:
State:
Zip:
State:
Zip:
Policy Number: Company Name: Company Address: City: Additional Information:
This form can be turned in when you check-in at camp. All leaders and all youth must have a current BSA Medical/Health form filled out and ready to turn-in at camp check-in. They will be returned at check-out. I state that the above information is correct. Signed by a Unit Leader
Date
Notes