Boy Scout Test




Part A: Informed Consent, Release Agreement, and Authorization A Full name: ________________________________________

DOB: ________________________________________

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/ Con dential Health Information (PHI/CHI) under the Standards for Privacy of Individually Identi able Health Information, 45 C.F.R. §§160.103, 164.501, etc. seq., as amended from time to time, includes examination ndings, 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/ lm/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/ lm/videotapes/electronic representations and/or sound recordings without limitation at the discretion of the BSA, and I speci cally 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

________________________________________________________  

High-adventure base participants:

Expedition/crew No.: _______________________________ or staff position: ___________________________________

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 speci cally 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: ______________________________________________________

Telephone: __________________________________________________

Adults NOT Authorized to Take Youth To and From Events:

Name: ______________________________________________________ Telephone: __________________________________________________

Name: ______________________________________________________ Telephone: __________________________________________________

Name: ______________________________________________________ Telephone: __________________________________________________

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Part B: General Information/Health History B Full name: ________________________________________

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?

High-adventure base participants:

Expedition/crew No.: _______________________________ or staff position: ___________________________________

!

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 dif culties

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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Part B: General Information/Health History B Full name: ________________________________________

DOB: ________________________________________

Allergies/Medications

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

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.

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 suf cient 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.

High-adventure base participants:

Expedition/crew No.: _______________________________ or staff position: ___________________________________

Yes

No

Allergies or Reactions

Explain

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

In uenza

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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Part C: Pre-Participation Physical C This part must be completed by certi ed and licensed physicians (MD, DO), nurse practitioners, or physician assistants.

Full name: ________________________________________

DOB: ________________________________________

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.

High-adventure base participants:

Expedition/crew No.: _______________________________ or staff position: ___________________________________

Examiner: Please ll in the following information:

Yes

No

Explain

Medical restrictions to participate

Yes

No

Allergies or Reactions

Explain

Yes

No

Allergies or Reactions

Explain

Medication

Plants

Food

Insect bites/stings

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

Examiner's Certi cation

I certify that I have reviewed the health history and examined this person and nd no contraindications for participation in a Scouting experience. This participant (with noted restrictions):

Normal

Abnormal

Explain Abnormalities

Eyes

Ears/nose/ throat

Lungs

Heart

Abdomen

Genitalia/hernia

Musculoskeletal

Neurological

Other

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.

Height/Weight Restrictions

Examiner's Signature: ___________________________________ Date: _______________ Provider printed name: ________________________________________________________ Address: ______________________________________________________________________ City:_____________________________________State: ____________ ZIP code: _________ Of ce phone: _________________________________________________

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

680-001 2014 Printing


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