A Part A: Informed Consent, Release Agreement, and Authorization High-adventure base participants: Full name: ______________ Expedition/crew No.: ___________ or staff position: _____________ DOB: ______________ Informed Consent, Release Agreement, and Authorization 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 I understand that participation in Scouting activities involves the risk of personal completely release and waive any and all claims for personal injury, death, or injury, including death, due to the physical, mental, and emotional challenges in the loss that may arise against the Boy Scouts of America, the local council, the activities offered. Information about those activities may be obtained from the venue, activity coordinators, and all employees, volunteers, related parties, or other activity coordinators, or your local council. I also understand that participation in organizations associated with any program or activity. these activities is entirely voluntary and requires participants to follow instructions and abide by all applicable rules and the standards of conduct. 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 In case of an emergency involving me or my child, I understand that efforts will publish the photographs/film/videotapes/electronic representations and/or sound be made to contact the individual listed as the emergency contact person by recordings made of me or my child at all Scouting activities, and I hereby release the medical provider and/or adult leader. In the event that this person cannot be the Boy Scouts of America, the local council, the activity coordinators, and all reached, permission is hereby given to the medical provider selected by the adult employees, volunteers, related parties, or other organizations associated with leader in charge to secure proper treatment, including hospitalization, anesthesia, the activity from any and all liability from such use and publication. I further surgery, or injections of medication for me or my child. Medical providers are authorize the reproduction, sale, copyright, exhibit, broadcast, electronic storage, authorized to disclose protected health information to the adult in charge, camp and/or distribution of said photographs/film/videotapes/electronic representations medical staff, camp management, and/or any physician or health-care provider and/or sound recordings without limitation at the discretion of the BSA, and I involved in providing medical care to the participant. Protected Health Information/ specifically waive any right to any compensation I may have for any of the foregoing. Confidential Health Information (PHI/CHI) under the Standards for Privacy of Individually Identifiable Health Information, 45 C.F.R. §§160.103, 164.501, etc. NOTE: Due to the nature of programs and seq., as amended from time to time, includes examination findings, test results, and activities, the Boy Scouts of America and local treatment provided for purposes of medical evaluation of the participant, follow-up councils cannot continually monitor compliance and communication with the participant’s parents or guardian, and/or determination ! of program participants or any limitations ! of the participant’s ability to continue in the program activities. imposed upon them by parents or medical providers. However, so that leaders can be as (If applicable) I have carefully considered the risk involved and hereby give my familiar as possible with any limitations, list any informed consent for my child to participate in all activities offered in the program. restrictions imposed on a child participant in I further authorize the sharing of the information on this form with any BSA volunteers connection with programs or activities below. or professionals who need to know of medical conditions that may require special consideration in conducting Scouting activities. List participant restrictions, if any: None ____________________ 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) 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. Name: __________________ Name: __________________ Telephone: __________________ Telephone: __________________ Adults NOT Authorized to Take Youth To and From Events: Name: __________________ Name: __________________ Telephone: __________________ Telephone: __________________ 680-001 2014 Printing

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B Part B: General Information/Health History High-adventure base participants: Full name: ______________ Expedition/crew No.: ___________ or staff position: _____________ DOB: ______________ 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 680-001 2014 Printing

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
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B Part B: General Information/Health History High-adventure base participants: Full name: ______________ Expedition/crew No.: ___________ or staff position: _____________ DOB: ______________ 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. Please list any additional information Yes No Had Disease Immunization Date(s) about your medical history: Tetanus _________________ Pertussis _________________ Diphtheria _________________ Measles/mumps/rubella _________________ Polio DO NOT WRITE IN THIS BOX Chicken Pox Review for camp or special activity. Hepatitis A Reviewed by: ________________ Hepatitis B Date: ___________________ Meningitis Further approval required: Yes No Influenza Reason: __________________ Other (i.e., HIB) Approved by: ________________ Exemption to immunizations (form required) Date: ___________________ 680-001 2014 Printing

Yes	No	Allergies or Reactions
		Medication
		Food

Yes	No	Allergies or Reactions	Explain
		Plants
		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)

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: ___________________

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Original PDF: bsa_med_form_a_b.pdf