Fillable Printable Philmont - Boy Scouts of America

Philmont - 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: ______________________________________________

! !

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

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Philmont Scout Ranch

High-Adventure Risk Advisory to

Health-Care Providers and Parents

Philmont Scout Ranch Experience. The Philmont

experience is not risk-free. Staff will instruct participants in safety

measures. Be prepared to listen to and follow these measures.

Accept responsibility for the health and safety of yourself and

others. Each participant must be able to carry 25 to 35 percent

of their body weight while hiking 5 to 12 miles per day in an

isolated mountain wilderness ranging from 6,500 to 12,500

feet in elevation over trails that are steep and rocky. Summer/

autumn climate includes temperatures from 30 to 100 degrees,

low humidity (10 to 30 percent), and frequent, sometimes severe,

thunderstorms. Winter climatic conditions can range from –20 to

60 degrees. During a Winter Adventure experience, each person

will walk, ski, or snowshoe along snow-covered trails pulling

loaded toboggans or sleds for up to 3 miles—or even more on a

cross-country ski trek.

Risk Advisory. Philmont has an excellent health and safety

record and strives to minimize risks to participants by emphasizing

appropriate safety precautions. Because most participants are

prepared, are conscious of risks, and take safety precautions,

they do not experience injuries. If you decide to attend Philmont,

you should be physically ﬁt, have proper clothing and equipment,

be willing to follow instructions, work as a team with your crew,

and take responsibility for your own health and safety.

Philmont staff members are trained in ﬁrst aid, CPR, and accident

prevention. They can assist the adult advisor in recognizing,

reacting to, and responding to accidents, injuries, and illnesses.

Each crew is required to have at least two members trained in

wilderness ﬁrst aid and CPR. Response times can be affected

by location, terrain, weather, or other emergencies and could be

delayed for hours or even days in a wilderness setting.

All Philmont participants should understand potential health risks

inherent at or above 6,700 feet in elevation in a dry Southwest

environment. High elevation; a physically demanding high-

adventure program in remote mountainous areas; camping while

being exposed to occasional severe weather conditions such

as lightning, hail, ﬂash ﬂoods, and heat; and other potential

problems, including injuries from tripping and falling, falls from

horses, heat exhaustion, and motor vehicle accidents, can

worsen underlying medical conditions. Native wild animals such

as bears, rattlesnakes, and mountain lions usually present little

danger if proper precautions are taken.

Guests attending Philmont Training Center conferences and

family programs who are unfamiliar with the backcountry should

review the supplemental information available on the Philmont

website, especially information about activities that may be new

to them.

Please call Philmont at 575-376-2281 if you have any questions.

All participants and guests should review all materials and

websites related to the experiences they are planning to have at

Philmont Scout Ranch.

Food. If the diet described in the participant guide does not

meet the participant’s special dietary needs, contact Philmont

directly. Visit the Philmont Scout Ranch website for sample

menus and more information.

Medication. Each participant who needs medication must

bring enough medicine for the duration of the trip. Consider

bringing two or three supplies of vital medication. People with

allergies that have resulted in severe reactions or anaphylaxis

must bring an EpiPen that has not expired.

Immunizations. Each participant must have received a

tetanus immunization within the last 10 years. Recognition will be

given to the rights of those Scouts and Scouters who do not have

immunizations because of philosophical, political, or religious

beliefs. In such a situation, the Immunization Exemption Request

form is required; it is located on the Philmont website.

High Blood Pressure. Upon arrival at Philmont, all adult

participants will have their blood pressure checked. Participants

should have a blood pressure less than 140/90. People with

hypertension (greater than 140/90) should be treated and

controlled before attending Philmont, and should continue on

medications while participating. The goal of treatment should be

to lower the blood pressure to normal levels. Those individuals

with a blood pressure consistently greater than 160/100 at

Philmont may be kept off the trail until their blood pressure

decreases.

Seizures (Epilepsy). The seizure disorder must be

well-controlled by medication. A well-controlled disorder is one

in which a year has passed without a seizure. Exceptions to this

guideline may be considered on an individual basis, and will

be based on the speciﬁc type of seizure and likely risks to the

individual/other members of the crew.

Diabetes Mellitus. Both the person with diabetes and

one other person in the group need to be able to recognize signs

of excessively high or low blood sugar. An insulin-dependent

person who was diagnosed or who has had a change in delivery

system (e.g., insulin pump) in the last six months is advised not

to participate. A person with diabetes who has had frequent

hospitalizations or who has had problems with low blood sugar

should not participate until better control of the diabetes has

been achieved. If an individual has been hospitalized for diabetes-

related illnesses within the past year, the individual must obtain

permission to participate by contacting the Philmont Health

Lodge at 575-376-2281.

Asthma. Asthma must be well-controlled before participating

at Philmont. This means: 1) the use of a rescue inhaler

(e.g., albuterol) less than once daily; 2) no need for a rescue

inhaler at night. Well-controlled asthma may include the use of

long-acting bronchodilators, inhaled steroids, or oral medications

such as Singulair. You may not be allowed to participate if: 1) you

have asthma not controlled by medication; or 2) you have been

hospitalized/gone to the emergency room to treat asthma in the

past six months; or 3) you have needed treatment by oral steroids

(prednisone) in the past six months. You must bring an ample

supply of your medication and a spare rescue inhaler that are not

expired. At least one other member of the crew should know how

to use the rescue inhaler. Any person who has needed treatment

for asthma in the past three years must carry a rescue inhaler on

the trek. If you do not bring a rescue inhaler, you must buy one

before you will be allowed to participate.

Phone: 575-376-2281 Website: www.philmontscoutranch.org

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Philmont Scout Ranch

High-Adventure Risk Advisory to

Health-Care Providers and Parents

Recommendations for Chronic Illnesses.

Adults or youth with any of the following conditions should

undergo an evaluation by a physician before considering

participation at Philmont.

1. Chest pain, myocardial infarction (heart attack) or family

history of heart disease in any person before age 50

2. Heart surgery, including angioplasty (balloon dilation), to

treat blocked blood vessels or place stents

3. Stroke or transient ischemic attacks (TIAs)

4. High blood pressure

5. Claudication (leg pain with exercise, caused by hardening of

the arteries)

6. Diabetes

7. Smoking or excessive weight

The physical exertion at Philmont may precipitate either a heart

attack or stroke in susceptible people. Participants with a

history of any of the seven conditions listed above should have

a physician-supervised stress test. Even if the stress test results

are normal, the results of testing are done at lower elevations,

without backpacks, and do not guarantee safety. If the test results

are abnormal, the individual is advised not to participate.

Allergy or Anaphylaxis. People who have had an

anaphylactic reaction from any cause must contact Philmont

before arrival. If you are allowed to participate, you will be

required to have appropriate treatment with you. You and at

least one other member of your crew must know how to give the

treatment. If you do not bring appropriate treatment with you, you

will be required to buy it before you will be allowed to participate.

Recent Musculoskeletal Injuries and

Orthopedic Surgery. Participants will put a great

deal of strain on their joints. Individuals who have signiﬁcant

musculoskeletal problems (including back problems) or

orthopedic surgery/injuries within the last six months must have a

letter of clearance from their treating physician to be considered

for approval, and Philmont should be contacted in advance of

participation. Permission is not guaranteed. Ingrown toenails are

a common problem and must be treated 30 days prior to arrival.

Psychological and Emotional Difﬁculties.

Parents and advisors should be aware that no high-adventure

experience is designed to assist participants in overcoming

psychological or emotional problems. Experience demonstrates

that these problems frequently become worse, when a participant

is under the stress of the physical and mental challenges of a

remote wilderness setting. Medication must never be stopped

prior to participation and should be continued throughout the

entire Philmont experience.

Weight Limits. Weight limit guidelines (see Part C) are

used because overweight individuals are at a greater risk for

heart disease, high blood pressure, stroke, altitude illness, sleep

problems, and injury. These guidelines are for all Scouting high-

adventure activities. Each participant’s weight must be less than

the maximum acceptable limit in the weight chart. Participants

21 years and older who exceed the maximum acceptable weight

limit for their height at the Philmont medical recheck WILL NOT

be permitted to backpack or hike at Philmont. They will be sent

home. For participants under 21 years of age who exceed the

maximum acceptable weight for height, the Philmont staff will

use their judgment to determine if the youth can participate.

Philmont will consider up to 20 pounds over the maximum

acceptable; however, exceptions are not made automatically and

discussion with Philmont in advance is required for any exception.

Philmont’s telephone number is 575-376-2281. Due to rescue

equipment restrictions and evacuation efforts from remote sites,

under no circumstances will any individual weighing more than

295 pounds be permitted to participate in backcountry programs.

Philmont Approval. Staff and/or staff physicians

reserve the right to deny the participation of any individual on

the basis of a physical examination and/or medical history.

Each participant is subject to a medical recheck at Philmont.

Phone: 575-376-2281 Website: www.philmontscoutranch.org