Fillable Printable Parts A, B & C - Boy Scouts of America

Parts A, B & C - Boy Scouts of America

Part A: Informed Consent, Release Agreement, and Authorization

Full name: ________________________________________

DOB: ________________________________________

High-adventure base participants:

Expedition/crew No.: _______________________________

or staff position: ___________________________________

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Complete this section for youth participants only:

Adults Authorized to Take to and From Events:

You must designate at least one adult. Please include a telephone number.

I understand that, if any information I/we have provided is found to be inaccurate, it may limit and/or eliminate the opportunity for participation in any event or activity. If I

am participating at Philmont, Philmont Training Center, Northern Tier, Florida Sea Base, or the Summit Bechtel Reserve, I have also read and understand the supplemental

risk advisories, including height and weight requirements and restrictions, and understand that the participant will not be allowed to participate in applicable high-adventure

programs if those requirements are not met. The participant has permission to engage in all high-adventure activities described, except as speciﬁcally noted by me or the

health-care provider. If the participant is under the age of 18, a parent or guardian’s signature is required.

Participant’s signature: ________________________________________________________________________________________ Date: ______________________________

Parent/guardian signature for youth: _____________________________________________________________________________ Date: ______________________________

(If participant is under the age of 18)

Second parent/guardian signature for youth: ______________________________________________________________________ Date: ______________________________

(If required; for example, California)

Name: ______________________________________________________

Telephone: __________________________________________________

Name: ______________________________________________________

Telephone: __________________________________________________

Adults NOT Authorized to Take Youth To and From Events:

Name: ______________________________________________________

Telephone: __________________________________________________

Name: ______________________________________________________

Telephone: __________________________________________________

Informed Consent, Release Agreement, and Authorization

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 your 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 me or my child, I understand that efforts will

be made to contact the individual listed as the emergency contact person by

the medical provider and/or adult leader. In the event that this person cannot be

reached, permission is hereby given to the medical provider selected by the adult

leader in charge to secure proper treatment, including hospitalization, anesthesia,

surgery, or injections of medication for me or my child. Medical providers are

authorized to disclose protected health information to the adult in charge, camp

medical staff, camp management, 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.

(If applicable) I have carefully considered the risk involved and hereby give my

informed consent for my child to participate in all activities offered in the program.

I further authorize the sharing of the information on this form with any BSA volunteers

or professionals who need to know of medical conditions that may require special

consideration in conducting Scouting activities.

With appreciation of the dangers and risks associated with programs and

activities, 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.

I also hereby assign and grant to the local council and the Boy Scouts of America,

as well as their authorized representatives, the right and permission to use and

publish the photographs/ﬁlm/videotapes/electronic representations and/or sound

recordings made of me or my child at all Scouting activities, and I hereby release

the Boy Scouts of America, the local council, the activity coordinators, and all

employees, volunteers, related parties, or other organizations associated with

the activity from any and all liability from such use and publication. I further

authorize the reproduction, sale, copyright, exhibit, broadcast, electronic storage,

and/or distribution of said photographs/ﬁlm/videotapes/electronic representations

and/or sound recordings without limitation at the discretion of the BSA, and I

speciﬁcally waive any right to any compensation I may have for any of the foregoing.

NOTE: Due to the nature of programs and

activities, 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. However, so that leaders can be as

familiar as possible with any limitations, list any

restrictions imposed on a child participant in

connection with programs or activities below.

List participant restrictions, if any: None

________________________________________________________

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Part B: General Information/Health History

Full name: ________________________________________

DOB: ________________________________________

High-adventure base participants:

Expedition/crew No.: _______________________________

or staff position: ___________________________________

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Age: ___________________________ Gender: ________________________ Height (inches): __________________________ Weight (lbs.): ____________________________

Address: ________________________________________________________________________________________________________________________________________

City: __________________________________________ State: __________________________ ZIP code: ______________ Telephone: ______________________________

Unit leader: ________________________________________________________________________________ Mobile phone: _________________________________________

Council Name/No.: __________________________________________________________________________________________________ Unit No.: ____________________

Health/Accident Insurance Company: _________________________________________________ Policy No.: ___________________________________________________

Please attach a photocopy of both sides of the insurance card. If you do not have medical insurance,

enter “none” above.

In case of emergency, notify the person below:

Name: ___________________________________________________________________________ Relationship: ___________________________________________________

Address: ____________________________________________________________ Home phone: _______________________ Other phone: _________________________

Alternate contact name: ____________________________________________________________ Alternate’s phone: ______________________________________________

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Health History

Do you currently have or have you ever been treated for any of the following?

Yes No Condition Explain

Diabetes

Last HbA1c percentage and date:

Hypertension (high blood pressure)

Adult or congenital heart disease/heart attack/chest pain

(angina)/heart murmur/coronary artery disease. Any heart

surgery or procedure. Explain all “yes” answers.

Family history of heart disease or any sudden heart-

related death of a family member before age 50.

Stroke/TIA

Asthma

Last attack date:

Lung/respiratory disease

COPD

Ear/eyes/nose/sinus problems

Muscular/skeletal condition/muscle or bone issues

Head injury/concussion

Altitude sickness

Psychiatric/psychological or emotional difﬁculties

Behavioral/neurological disorders

Blood disorders/sickle cell disease

Fainting spells and dizziness

Kidney disease

Seizures

Last seizure date:

Abdominal/stomach/digestive problems

Thyroid disease

Excessive fatigue

Obstructive sleep apnea/sleep disorders

CPAP: Yes £ No £

List all surgeries and hospitalizations

Last surgery date:

List any other medical conditions not covered above

Part B: General Information/Health History

Full name: ________________________________________

DOB: ________________________________________

High-adventure base participants:

Expedition/crew No.: _______________________________

or staff position: ___________________________________

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Allergies/Medications

Are you allergic to or do you have any adverse reaction to any of the following?

Yes No Allergies or Reactions Explain Yes No Allergies or Reactions Explain

Medication Plants

Food Insect bites/stings

List all medications currently used, including any over-the-counter medications.

CHECK HERE IF NO MEDICATIONS ARE ROUTINELY TAKEN. IF ADDITIONAL SPACE IS NEEDED, PLEASE

INDICATE ON A SEPARATE SHEET AND ATTACH.

Medication Dose Frequency Reason

YES NO Non-prescription medication administration is authorized with these exceptions:_______________________________________________

Administration of the above medications is approved for youth by:

_______________________________________________________________________ / _______________________________________________________________________

Parent/guardian signature MD/DO, NP, or PA signature (if your state requires signature)

Bring enough medications in sufﬁcient quantities and in the original containers. Make sure that they

are NOT expired, including inhalers and EpiPens. You SHOULD NOT STOP taking any maintenance

medication unless instructed to do so by your doctor.

! !

Immunization

The following immunizations are recommended by the BSA. Tetanus immunization is required and must have been received within the last 10 years. If you had the disease,

check the disease column and list the date. If immunized, check yes and provide the year received.

Yes No Had Disease Immunization Date(s)

Tetanus

Pertussis

Diphtheria

Measles/mumps/rubella

Polio

Chicken Pox

Hepatitis A

Hepatitis B

Meningitis

Inﬂuenza

Other (i.e., HIB)

Exemption to immunizations (form required)

Please list any additional information

about your medical history:

_____________________________________________

DO NOT WRITE IN THIS BOX

Review for camp or special activity.

Reviewed by: ____________________________________________

Date: ___________________________________________________

Further approval required:

Yes No

Reason: ________________________________________________

Approved by: ____________________________________________

Date: ___________________________________________________

Part C: Pre-Participation Physical

This part must be completed by certiﬁed and licensed physicians (MD, DO), nurse practitioners, or physician assistants.

Full name: ________________________________________

DOB: ________________________________________

High-adventure base participants:

Expedition/crew No.: _______________________________

or staff position: ___________________________________

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You are being asked to certify that this individual has no contraindication for participation inside a

Scouting experience. For individuals who will be attending a high-adventure program, including one

of the national high-adventure bases, please refer to the supplemental information on the following

pages or the form provided by your patient.

Examiner: Please ﬁll in the following information:

Yes No Explain

Medical restrictions to participate

Height/Weight Restrictions

If you exceed the maximum weight for height as explained in the following chart and your planned high-adventure activity will take you more than 30 minutes away from an

emergency vehicle/accessible roadway, you may not be allowed to participate.

Maximum weight for height:

Height (inches) Max. Weight Height (inches) Max. Weight Height (inches) Max. Weight Height (inches) Max. Weight

60 166 65 195 70 226 75 260

61 172 66 201 71 233 76 267

62 178 67 207 72 239 77 274

63 183 68 214 73 246 78 281

64 189 69 220 74 252 79 and over 295

Examiner’s Certiﬁcation

I certify that I have reviewed the health history and examined this person and ﬁnd

no contraindications for participation in a Scouting experience. This participant

(with noted restrictions):

True False Explain

Meets height/weight requirements.

Does not have uncontrolled heart disease, asthma, or hypertension.

Has not had an orthopedic injury, musculoskeletal problems, or

orthopedic surgery in the last six months or possesses a letter of

clearance from his or her orthopedic surgeon or treating physician.

Has no uncontrolled psychiatric disorders.

Has had no seizures in the last year.

Does not have poorly controlled diabetes.

If less than 18 years of age and planning to scuba dive, does not have

diabetes, asthma, or seizures.

For high-adventure participants, I have reviewed with them the

important supplemental risk advisory provided.

Examiner’s Signature: ___________________________________ Date: _______________

Provider printed name: ________________________________________________________

Address: ______________________________________________________________________

City: _____________________________________State: ____________ ZIP code: _________

Ofﬁce phone: _________________________________________________

Normal Abnormal Explain Abnormalities

Eyes

Ears/nose/

throat

Lungs

Heart

Abdomen

Genitalia/hernia

Musculoskeletal

Neurological

Other

Height (inches):__________________ Weight (lbs.):__________________ BMI:__________________ Blood Pressure:__________________/__________________ Pulse:__________________

Yes No Allergies or Reactions Explain Yes No Allergies or Reactions Explain

Medication Plants

Food Insect bites/stings