High-adventure base participants:
Expedition/crew No.: __________________________________________________
or staff position: _______________________________________________________
680-001
2011 Printing
Rev. 2/2011
Full name: _________________________________ DOB: ______________ Allergies: __________________ Emergency contact No.: ___________________
Annual BSA Health and Medical Record
Part A
GENERAL INFORMATION
Name ___________________________________________________________________ Date of birth ________________________________ Age _____________ Male Female
Address _________________________________________________________________________________________________________________________ Grade completed (youth only) __________
City _____________________________________________________________________ State ____________ Zip ____________________________ Phone No. ________________________________
Unit leader ______________________________________________________ Council name/No. ___________________________________________ Unit No. ___________________
Social Security No. (optional; may be required by medical facilities for treatment) _______________________ Religious preference ______________________________
Health/accident insurance company __________________________________________________________ Policy No. ________________________________________________________
ATTACH A PHOTOCOPY OF BOTH SIDES OF INSURANCE CARD. IF FAMILY HAS NO MEDICAL INSURANCE, STATE “NONE.”
In case of emergency, notify:
Name _________________________________________________________________________________ Relationship _____________________________________________________________
Address _________________________________________________________________________________________________________________________________________________________________
Home phone _________________________________________ Business phone _______________________________ Cell phone ___________________________________________
Alternate contact _________________________________________________________________________ Alternate’s phone ___________________________________________________
HEALTH HISTORY
Are you now, or have you ever been treated for any of the following: Allergies or Reaction to:
Yes No Condition Explain
Medication ____________________________________
Food, Plants, or Insect Bites _________________
_________________________________________________
Immunizations:
The following are recommended by the BSA.
Tetanus immunization is required and must
have been received within the last 10 years. If
had disease, put “D” and the year. If immunized,
check the box and the year received.
Yes No Date
Tetanus ________________________
Pertussis _______________________
Diphtheria ______________________
Measles ________________________
Mumps _________________________
Rubella _________________________
Polio ____________________________
Chicken pox____________________
Hepatitis A _____________________
Hepatitis B _____________________
Influenza _______________________
Other (i.e., HIB) ________________
Exemption to immunizations claimed
(form required).
Asthma Last attack: ____________
Diabetes Last HbA1c: ____________
Hypertension (high blood pressure)
Heart disease (e.g., CHF, CAD, MI)
Stroke/TIA
Lung/respiratory disease
Ear/sinus problems
Muscular/skeletal condition
Menstrual problems (women only)
Psychiatric/psychological and
emotional difficulties
Behavioral disorders (e.g., ADD,
ADHD, Asperger syndrome, autism)
Bleeding disorders
Fainting spells
Thyroid disease
Kidney disease
Sickle cell disease
Seizures Last seizure: ____________
Sleep disorders (e.g., sleep apnea)
Use CPAP: Yes
No
Abdominal/digestive problems
Surgery
Serious injury
Other
MEDICATIONS
List all medications currently used. (If additional space is needed, please photocopy
this part of the health form.) Inhalers and EpiPen information must be included, even
if they are for occasional or emergency use only.
Medication _____________________________
Strength ________ Frequency ____________
Approximate date started ________________
Reason for medication ___________________
________________________________________
Medication _____________________________
Strength ________ Frequency ____________
Approximate date started ________________
Reason for medication ___________________
________________________________________
Medication _____________________________
Strength ________ Frequency ____________
Approximate date started ________________
Reason for medication ___________________
________________________________________
Medication _____________________________
Strength ________ Frequency ____________
Approximate date started ________________
Reason for medication ___________________
________________________________________
Medication _____________________________
Strength ________ Frequency ____________
Approximate date started ________________
Reason for medication ___________________
________________________________________
Medication _____________________________
Strength ________ Frequency ____________
Approximate date started ________________
Reason for medication ___________________
________________________________________
Administration of the above medications is approved by (if required by your state): ________________________ / _______________________
Parent/guardian signature and/or MD/DO, NP, or PA signature
Be sure to bring medications in sufficient quantities and the original containers. Make sure that they are NOT
expired, including inhalers and EpiPens. You SHOULD NOT STOP taking any maintenance medication.
(For more information about immunizations,
as well as the immunization exemption form,
see Scouting Safely on Scouting.org.)
High-adventure base participants:
Expedition/crew No.: __________________________________________________
or staff position: _______________________________________________________
680-001
2011 Printing
Rev. 2/2011
Part B
INFORMED CONSENT AND HOLD HARMLESS/RELEASE AGREEMENT
I understand that participation in Scouting activities involves a certain degree of risk and can be physically, mentally, and emotionally
demanding. I also understand that participation in these activities is entirely voluntary and requires participants to abide by applicable
rules and standards of conduct.
In case of an emergency involving me or my child, I understand that every effort will be made to contact the individual listed as the
emergency contact person. 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.
I have carefully considered the risk involved and give consent for myself and/or my child to participate in these activities. I approve
the sharing of the information on this form with BSA volunteers and professionals who need to know of medical situations that might
require special consideration for the safe conducting of Scouting activities.
I 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 claims or liability arising out of this participation.
Without restrictions.
With special considerations or restrictions (list) ____________________________________________________________________________________________
____________________________________________________________________________________________________________________________________________________
TALENT RELEASE AGREEMENT
I hereby assign and grant to the local council and the Boy Scouts of America 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 hereby 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 Boy Scouts of America,
and I specifically waive any right to any compensation I may have for any of the foregoing.
Yes No
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, or Florida Sea Base: I have also read and
understand the risk advisories explained in Part D, 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.
Participant’s name _______________________________________________________________________________________________________
Participant’s signature __________________________________________________________________ Date ____________________________
Parent/guardian’s signature ______________________________________________________________ Date ____________________________
(if participant is under the age of 18)
Second parent/guardian signature ________________________________________________________ Date ____________________________
(if required; for example, CA)
This Annual Health and Medical Record is valid for 12 calendar months.
ADULTS AUTHORIZED TO TAKE YOUTH TO AND FROM EVENTS:
You must designate at least one adult. Please include a telephone number.
1. Name _________________________________________________________________ Telephone ______________________________________
2. Name _________________________________________________________________ Telephone ______________________________________
3. Name _________________________________________________________________ Telephone ______________________________________
Adults NOT authorized to take youth to and from events:
1. Name __________________________________________________________________________________________________________________
2. Name __________________________________________________________________________________________________________________
3. Name __________________________________________________________________________________________________________________
Part B Full name: ___________________________________________________________ DOB: __________________
High-adventure base participants:
Expedition/crew No.: __________________________________________________
or staff position: _______________________________________________________
680-001
2011 Printing
Rev. 2/2011
Part C
TO THE EXAMINING HEALTH-CARE PROVIDER (Certified and licensed physicians [MD, DO], nurse practitioners, and physician’s assistants)
You are being asked to certify that this individual has no contraindication for participation in a Scouting experience. For individuals who will be attending a
high-adventure program at one of the national high-adventure bases, please refer to Part D for additional information.
(Part D was made available to me. ❏ Yes ❏ No)
PHYSICAL EXAMINATION
Height (inches) ____________ Weight (pounds)______________ Maximum weight for height __________ Meets height/weight limits Yes No
Blood pressure _______________________ Pulse __________________ Percent body fat (optional) __________________
If you exceed the maximum weight for height as explained on this page and your planned high-adventure activity will take you more than 30 minutes
away from an emergency vehicle–accessible roadway, you will not be allowed to participate. At the discretion of the medical advisors of the event
and/or camp, participation of an individual exceeding the maximum weight for height may be allowed if the body fat percentage measured by the
health-care provider is determined to be 20 percent or less for a female or 15 percent or less for a male. (Philmont requires a water-displacement
test to be used for this determination.) Please call the event leader and/or camp if you have any questions. Enforcing the height/weight guidelines is
strongly encouraged for all other events.
Normal Abnormal
Explain Any
Abnormalities
Range of Mobility Normal Abnormal
Explain Any
Abnormalities
Eyes Knees (both)
Ears Ankles (both)
Nose Spine
Throat
Lungs
Neurological
Other Yes No
Heart Contacts
Abdomen Dentures
Genitalia Braces
Skin Inguinal hernia
Explain
Emotional
adjustment
Medical equipment
(i.e., CPAP, oxygen)
Tuberculosis (TB) skin test (if required by your state for BSA camp staff)
Negative Positive
Allergies (to what agent, type of reaction, treatment): ____________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________________________________
Restrictions
(if none, so state) ____________________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________
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 above)
True False
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 their 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
Provider printed name _______________________________________________________
Address _________________________________________________________________________
City, state, zip __________________________________________________________________
Office phone ___________________________________________________________________
Signature ________________________________________________________________________
Date ______________________________________________________________________________
Height
(inches)
Recommended
Weight (lbs)
Allowable
Exception
Maximum
Acceptance
60 97-138 139-166 166
61 101-143 144-172 172
62 104-148 149-178 178
63 107-152 153-183 183
64 111-157 158-189 189
65 114-162 163-195 195
66 118-167 168-201 201
67 121-172 173-207 207
68 125-178 179-214 214
69 129-185 186-220 220
70 132-188 189-226 226
71 136-194 195-233 233
72 140-199 200-239 239
73 144-205 206-246 246
74 148-210 211-252 252
75 152-216 217-260 260
76 156-222 223-267 267
77 160-228 229-274 274
78 164-234 235-281 281
79 & over 170-240 241-295 295
This table is based on the revised Dietary Guidelines for Americans from the U.S.
Dept. of Agriculture and the Dept. of Health & Human Services.
Part C Full name: ______________________________________________________________ DOB: ________________
DO NOT WRITE IN THIS BOX
REVIEW FOR CAMP OR SPECIAL ACTIVITY
Reviewed by ____________________________________________________________________________________________________ Date _______________________________
Further approval required ❏ Yes ❏ No Reason ________________________________________________________________________________________________________
By ______________________________________________________________________________________________________________ Date _______________________________
