A Part A: Informed Consent, Release Agreement, and Authorization Full name: _______________ High-adventure base participants: Expedition/crew No.: _________________ Date of birth: _______________ or staff position: _________________ Informed Consent, Release Agreement, and Authorization I understand that participation in Scouting activities involves the risk of personal injury, including I also hereby assign and grant to the local council and the Boy Scouts of America, as well as their death, due to the physical, mental, and emotional challenges in the activities offered. Information authorized representatives, the right and permission to use and publish the photographs/film/ about those activities may be obtained from the venue, activity coordinators, or your local council. videotapes/electronic representations and/or sound recordings made of me or my child at all I also understand that participation in these activities is entirely voluntary and requires participants Scouting activities, and I hereby release the Boy Scouts of America, the local council, the activity to follow instructions and abide by all applicable rules and the standards of conduct. 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 In case of an emergency involving me or my child, I understand that efforts will be made to reproduction, sale, copyright, exhibit, broadcast, electronic storage, and/or distribution of said contact the individual listed as the emergency contact person by the medical provider and/or photographs/film/videotapes/electronic representations and/or sound recordings without limitation adult leader. In the event that this person cannot be reached, permission is hereby given to the at the discretion of the BSA, and I specifically waive any right to any compensation I may have for medical provider selected by the adult leader in charge to secure proper treatment, including any of the foregoing. 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 Every person who furnishes any BB device to any minor, without the express or implied permission medical staff, camp management, and/or any physician or health-care provider involved in of the parent or legal guardian of the minor, is guilty of a misdemeanor. (California Penal Code providing medical care to the participant. Protected Health Information/Confidential Health Section 19915[a]) My signature below on this form indicates my permission. 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, I give permission for my child to use a BB device. (Note: Not all events will include BB devices.) 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.  Checking this box indicates you DO NOT want your child to use a BB device. (If applicable) I have carefully considered the risk involved and hereby give my informed consent NOTE: Due to the nature of programs and activities, the Boy Scouts of for my child to participate in all activities offered in the program. I further authorize the sharing America and local councils cannot continually monitor compliance of program of the information on this form with any BSA volunteers or professionals who need to know of participants or any limitations imposed upon them by parents or medical medical conditions that may require special consideration in conducting Scouting activities. 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 With appreciation of the dangers and risks associated with programs and activities, on my programs or activities below. 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 List participant restrictions, if any:  None of America, the local council, the activity coordinators, and all employees, volunteers, related parties, or other organizations associated with any program or activity. ____________________ 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 Scout Ranch, Philmont Training Center, Northern Tier, 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) Complete this section for youth participants only: Adults Authorized to Take Youth to and From Events: You must designate at least one adult. Please include a phone number. Name: _______________________ Name: _______________________ Phone: _______________________ Phone: _______________________ Adults NOT Authorized to Take Youth to and From Events: Name: _______________________ Name: _______________________ Phone: _______________________ Phone: _______________________ 680-001 2019 Printing

B1 Part B1: General Information/Health History Full name: _______________ High-adventure base participants: Expedition/crew No.: _________________ Date of birth: _______________ or staff position: _________________ Age: ____________Gender: __________ Height (inches): ___________ Weight (lbs.): __________ Address: _______________________________________________ City: ______________State: __________ZIP code: _______ Phone: __________ Unit leader: __________________________ Unit leader’s mobile #: _______________ 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: Insulin pump: Yes £ No £ 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/reactive airway disease Last attack date: Lung/respiratory disease COPD Ear/eyes/nose/sinus problems Muscular/skeletal condition/muscle or bone issues Head injury/concussion/TBI Altitude sickness Psychiatric/psychological or emotional difficulties Neurological/behavioral disorders Blood disorders/sickle cell disease Fainting spells and dizziness Kidney disease Seizures or epilepsy Last seizure date: Abdominal/stomach/digestive problems Thyroid disease Skin issues Obstructive sleep apnea/sleep disorders CPAP: Yes £ No £ List all surgeries and hospitalizations Last surgery date: List any other medical conditions not covered above 680-001 2019 Printing

Yes	No	Condition	Explain
		Diabetes
		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/reactive airway disease	Last attack date:
		Lung/respiratory disease
		COPD
		Ear/eyes/nose/sinus problems
		Muscular/skeletal condition/muscle or bone issues
		Head injury/concussion/TBI
		Altitude sickness
		Psychiatric/psychological or emotional difficulties
		Neurological/behavioral disorders
		Blood disorders/sickle cell disease
		Fainting spells and dizziness
		Kidney disease
		Seizures or epilepsy	Last seizure date:
		Abdominal/stomach/digestive problems
		Thyroid disease
		Skin issues
		Obstructive sleep apnea/sleep disorders	CPAP: Yes £ No £
		List all surgeries and hospitalizations
		List any other medical conditions not covered above

B2 Part B2: General Information/Health History Full name: _______________ High-adventure base participants: Expedition/crew No.: _________________ Date of birth: _______________ or staff position: _________________ Allergies/Medications DO YOU USE AN EPINEPHRINE  YES  NO DO YOU USE AN ASTHMA RESCUE  YES  NO AUTOINJECTOR? Exp. date (if yes) ___________ INHALER? Exp. date (if yes) _____________ 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 list 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. 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. Please list any additional information about your medical history: Yes No Had Disease Immunization Date(s) _______________ Tetanus _______________ Pertussis _______________ Diphtheria _______________ Measles/mumps/rubella Polio DO NOT WRITE IN THIS BOX. Review for camp or special activity. Chicken Pox Reviewed by: _______________ Hepatitis A Date: _________________ Hepatitis B   Further approval required: Yes No Meningitis Reason: _________________ Influenza Approved by: ________________ Other (i.e., HIB) Exemption to immunizations (form required) Date: _________________ 680-001 2019 Printing

Yes	No	Allergies or Reactions	Explain		Yes	No	Allergies or Reactions	Explain
		Medication					Plants
		Food					Insect bites/stings

Medication	Dose	Frequency	Reason

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)

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Original PDF: 680001_AB-1.pdf