Troop #: Council Name: One 6/22-28

Council Street Address: Two 6/29-7/5Council City, State and Zip: Three 7/6-12

Four 7/13-19Five 7/20-26

Date Reservation Made: Adams

Name of Unit Registrar: Arapahoe Unit Street Address: Arikera

Unit City, State and Zip: Cheyenne Phone 1: Crow Phone 2: Custer

Email: DakotaGordon Lakota

Lilliwaup NUMBER OF ATTENDEES Oglala

Adults: at $100 Reno Out of Council: at $250 Sioux

In Council: at $225 Sissiton In Council/FOS goal met at $200 Strauss

***HIGH ADVENTURE Teton HA Out of Council/In Council at $325HA In Council/FOS goal met at $300

Check #:

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Credit Card Number: Expiration Date:

3 Digit Code: Black Hills Area CouncilCredit Card Street Address : 144 North Street

Credit Card Zip Code: Rapid City, SD 57701

www.BlackHillsAreaCouncil.com

Only confirmed reservations will guarantee a spot!Troop deposit of $250.00 (which is non-refundable) confirms reservation.

2014 MMSR CAMP RESERVATION

*** Reminder: High Adventure fees are non-refundable.

**We will do our best to accommodate your request, however we reserve the right to make changes at any time.

**CAMPSITE PICK 3 (i.e., 1, 2, 3)

WEEK

Make checks payable to:

BLACK HILLS AREA COUNCILBoy Scouts of America

144 North Street, Rapid City, SD 57701P 605.342.2824 F 605.342.2826

Black Hills Area Council Boy Scouts of America Contact Person Phone Troop __________

Week In Camp Campsite Number of Patrols

Number of Scouts Number of Adults SUNDAY 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: Request Made: (Home) (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 - or - Insurance is provided by Council Unit Number: Council Name: Policy Holder’s Name: Policy Holder’s Address: City: State: Zip: Policy Number: Company Name: Company Address: City: State: Zip: 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