participant agreement and information - … · · 2013-12-26participant agreement and information...

AP14 Participant Agreement V2.2.docx 1 of 3 9/5/2013

PARTICIPANT AGREEMENT AND INFORMATION

ORDER OF THE ARROW – BOY SCOUTS OF AMERICA

• A separate copy of this form must be completed for each participant attending.• Total Cost for ArrowPower2014 will be $225, with a $100 deposit due by April 1, 2014. For those not registering

throught a Council, please make checks payable to Sioux Council.Some recreation choices may have an additional fee.

• Return this form to your council contingent coordinator so they can submit it to: Loren Meinke, 1938 GraydonAvenue, Brainerd, MN 56401 [email protected] (218)-‐270-‐2261

• For updated information: arrowpower.sectionc1b.org

Council Name: Council Number:

Name:

Birthday (MM/DD/YYYY): ___ / ___ / _______ Gender: ___________ Registered Unit Type/Number:

Street:

City: State: ZIP Code:

Email address:

Phone – Home: Work/School:

Phone – Mobile:

Relationship:

In case of emergency, contact:

Name:

Street:

City:

Phone – Home:

State: ZIP Code:

Work:

Mobil)______________

Physician’s Name: Phone: .

Allergies:

Medications:

Dietary Needs: (by June 30, 2014)

Height: ____________ Weight: ________________

All participants must be compliant with Philmont Height/Weight

Restrictions Any restrictions on activities:

[Abstract] [Abstract]


We certify that the participant submitted above is a registered member in good standing of the Boy Scouts of America (and if

an Arrowman, our OA Lodge). We give approval for his/her participation in the ArrowPower program.

Council Scout Executive or Designee Signature: ____________________________ Date:

Council Scout Executive or Designee Name (Print):

I agree to abide by the Participant Code of Conduct and to the terms of the Statement of Understanding (Participant), as

provided in this document; and I certify that my membership is current and paid in the Boy Scouts of America and Order of

the Arrow.

Applicant Signature: _________________________________________________ Date:

Applicant Name (Print):

Physical conditions/illnesses/diseases/limitations/etc?

Do you wear prescription eyeglasses:

• Date of Youth Protection Course (MM/DD/YYYY): ____________________• Date of Weather Hazard Training (MM/DD/YYYY): _____________________• Date of Safety Afloat Course (MM/DD/YYYY): ______________.

• Courses must be completed within two years of ArrowPower2014 event for participants 18 years and older.Highly recommended for all participants.

Training available online at myscouting.scouting.org

I have been trained in the methods of construction and/or maintaining trails:

HAT or other Trail Boss program; PCT Association; Other _______________

I have attended or been trained:

Philmont Trek; Philmont Trail Crew OATC; Wilderness Voyage OAWV/OACO; Florida Sea Base OAOA

ArrowCorps5; Conservation School; ArrowPower2011; Other:

I have a technical background (such as radios, computers, building construction…industry/trade):

I have the following medical training/certification (e.g., M.D., EMT…)

_____________________ .

Parent/Guardian Signature (If under 18 years of age): __________________________

Date : Parent/Guardian Name (Print):

[Abstract] [Abstract]


Participant Statement of Understanding And Code of Conduct

Statement of Understanding: All youth and adult participants are selected to represent their local council based on their qualifications in character, camping skills, physical and personal fitness, and leadership qualities.

Therefore, all youth participants and their parents or guardians are asked to sign the Statement of Understanding and Code of Conduct as a condition of participation, with the further understanding that serious misconduct or infraction of established rules and regulations may result in expulsion, at the participant’s expense, from ArrowPower2014. Ultimately we want each participant to be responsible for his or her own behavior, and only when necessary will the procedure be invoked to send a participant home from ArrowPower2014.

All youth and adult participants are expected to abide by the Code of Conduct as follows: 1. The lodge’s adult leadership (adviser or designee) is responsible for the supervision of its membership in respect to

maintaining discipline and security, and the participant Code of Conduct. 2. The Scout Oath and Law will be my guide throughout ArrowPower2014.3. I will set a good example by keeping myself neatly dressed for my position and work assignment. (Class A uniforms are to be

worn during check in, dinner, and event-‐wide shows.)4. I will attend all scheduled programs and will participate as required in cooperation with other lodge’s members and

leadership.5. In consideration of other lodge’s participants, I agree to follow the bedtime and other schedules of the event, or as otherwise

directed by the ArrowPower2014 program.6. I will be responsible for keeping my area and personal gear labeled, clean, and neat. I will adhere to all ArrowPower2014

recycling policies and regulations. I will do my share to prevent littering.7. I understand that the purchase, possession, and consumption of alcoholic beverages or illegal drugs by any youth and adult

members are prohibited. This standard shall apply to all who attend.8. Serious and/or repetitive violations by youth and adults including use of tobacco, alcohol, and drugs, cheating, stealing

dishonesty, swearing, fighting and cursing may result in expulsion from ArrowPower2014 or serious disciplinary action andloss of privileges. The Incident Commanders must be contacted for the expulsion procedure to be invoked. There are noexceptions.

9. I understand that gambling of any form is prohibited.10. I understand that possession of lasers of any type, and possession and detonation of fireworks are prohibited.11. I will demonstrate respect for Grand Marais High School, United States Forest Service and event property and be personally

responsible for any loss, breakage, or vandalism of property as a result of my actions.12. Neither the lodge adviser (or designee), ArrowPower2014 sponsors, nor the Order of the Arrow of the BSA, will be responsible

for loss, breakage, or theft of my personal items. I will label all my personal items and check items of value at the direction ofmy lodge’s adviser or his/her designee. Theft will be grounds for expulsion.

13. While participating in events and other activities, I will obey the safety rules and instructions of all supervisors and staffmembers.

14. Adult leaders and youth participants are prohibited from having firearms and weapons in possession in accordance withfederal, state, and local laws.

15. All youth and adult participants will be guided by the Scout Oath and Law and will obey all federal, state, and local laws.16. All adults, age 18 and over, must receive Youth Protection and Weather Hazard training prior to ArrowPower2014 and must

follow the guidelines therein.17. Hazing has no place in the Order of the Arrow of the Boy Scouts of America.18. Adult leaders should have the good judgment to avoid trading patches with a child or youth members in Scouting. Youth

members may trade with other youth members. Adult leaders may trade only with other adults 18 years of age or older.19. All youth and adult participants must avoid confrontation with groups, demonstrations, or hecklers, and must assume a

passive reaction to name-‐calling from individuals or groups.20. Serious violation of this Code of Conduct may result in expulsion from ArrowPower2014 at the participant’s own expense. All

decisions will be final.

OMB 0596-0080 (Expires 12/2013)

Optional Form 301a (09/2010) USDA-USDI

Volunteer Services Agreement for Natural Resources Agencies for Individuals or Groups Please print when completing this form (Attach a separate sheet for those data that do not fit in the allowed spaces).

Site Name/Project Leader Agency Reimbursement (if any)

Name of Volunteer or Group Leader – Last, First, Middle Age (If Individual Agreement)

Under 18 18-25 26-55 56 and Older

Are you a U.S. Citizen?

Yes No Visa Type

Email Address Home Phone Mobile Phone

Street Address City State Zip

IF VOLUNTEER IS UNDER AGE 18 – Name of Parent or Legal Guardian

Home Phone Mobile Phone Email Address


I affirm that I am the parent/guardian of the above named volunteer. I understand that the agency volunteer program does not provide compensation, except as otherwise provided by law; and that the service will not confer on the volunteer the status of a Federal employee. I have read the attached description of the service that the volunteer will perform. I give my permission for to participate in the specified volunteer activity sponsored

by at(Name of Sponsoring Organization, if applicable) (Name of Volunteer Duty Station)

From to (Date) (Date) (Parent/Guardian Signature) (Date)

Emergency Contact Name Home Phone Mobile Phone Email Address


GOVERNMENT OFFICIAL COMPLETES THIS SECTIONDescription of service to be performed. Include details such as time and schedule commitment, use of personal equipment, government vehicle, skills required (note certifications if necessary), level of physical activity required, etc. Attach the complete job description and job hazard analysis to this form. If this is a group agreement, the leader is to provide the group name, a complete list of group participants to be attached to this form, and parental approval (above) completed for each volunteer under the age of 18.

Government Vehicle required? Yes No Valid State Driver’s License International Driver’s License

Personal Vehicle to be used? Yes No Please verify that the volunteer is in possession of one of these documents. DO NOT keep a copy of the document for his/her file.

OMB 0596-0080 (Expires 12/2013)

2 Optional Form 301a (09/2010) USDA-USDI

I understand that I will not receive any compensation for the above service and that volunteers are NOT considered Federal employees for any purpose other than tort claims and injury compensation. I understand that volunteer service is not creditable for leave accrual or any other employee benefits. I also understand that either the government or I may cancel this agreement at any time by notifying the other party.

I understand that my volunteer position may require a reference check, background investigation, and/or a criminal history inquiry in order for me to perform my duties.

I understand that all publications, films, slides, videos, artistic or similar endeavors, resulting from my volunteer services as specifically stated in the attached job description, will become the property of the United States, and as such, will be in the public domain and not subject to copyright laws.

I understand the health and physical condition requirements for doing the work as described in the job description and at the project location, and certify that the statement I have checked below is true:

I know of no medical condition or physical limitation that may adversely affect my ability to provide this service.

I do know of a medical condition or physical limitation that may adversely affect my ability to provide this service and have explained it to .

(Name of Agency Official)

I do hereby volunteer my services as described above, to assist in agency-authorized work. I agree to follow all applicable safety guidelines.

(Signature of Volunteer) (Date)

The above - named agency agrees, while this arrangement is in effect, to provide such materials, equipment, and facilities that are available and needed to perform the service described above, and to consider you as a Federal employee only for the purposes of tort claims and injury compensation to the extent not covered by your volunteer group, if any.

(Signature of Government Representative) (Date)

Termination of Agreement

Volunteer requests formal evaluation Yes No Evaluation Completed(Date)

Agreement terminated on (Date) (Signature of Government Representative)

Public Burden StatementAccording to the Paperwork Reduction Act of 1995, an agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0596- 0080. The time required to complete this information collection is estimated to average 15 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. The U.S. Department of Agriculture (USDA) and U.S. Department of the Interior (USDI) prohibit discrimination in all programs and activities on the basis of race, color, national origin, gender, religion, age, disability, political beliefs, sexual orientation, and marital or family status. (Not all prohibited bases apply to all programs.) Persons with disabilities who require alternative means for communication of program information (Braille, large print, audiotape, etc.) should contact USDA’s TARGET Center at 202-720-2600 (voice and TDD). To file a complaint of discrimination, write USDA, Director, Office of Civil Rights, 1400 Independence Avenue, SW, Washington, DC 20250-9410 or call (800) 795-3272 (voice) or (202) 720-6382 (TDD). USDA and USDI are equal opportunity providers and employers.

Privacy Act Statement Collection and use is covered by Privacy Act System of Records OPM/GOVT-1 and USDA/OP-1, and is consistent with the provisions of 5 USC 552a (Privacy Act of 1974), which authorizes acceptance of the information requested on this form. The data will be used to maintain official records of volunteers of the USDA and USDI for the purposes of tort claims and injury compensation. Furnishing this data is voluntary, however if this form is incomplete, enrollment in the program cannot proceed.

participant agreement and information - … · · 2013-12-26participant agreement and information...

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