Annual Health and Medical Record (Valid for 12 calendar months) Medical Information The Boy Scouts of America recommends that all youth and adult members have annual medical evaluations by a certified and licensed health-care provider. In an effort to provide better care to those who may become ill or injured and to provide youth members and adult leaders a better understanding of their own physical capabilities, the Boy Scouts of America has established minimum standards for providing medical information prior to participating in various activities. Those standards are offered below in one three-part medical form. Note that unit leaders must always protect the privacy of unit participants by protecting their medical information. Parts A and C are to be completed annually by all BSA unit members. Both parts are required for all events that do not exceed 72 consecutive hours, where the level of activity is similar to that normally expended at home or at school, such as day camp, day hikes, swimming parties, or an overnight camp, and where medical care is readily available. Medical information required includes a current health history and list of medications. Part C also includes the parental informed consent and hold harmless/release agreement (with an area for notarization if required by your state) as well as a talent release statement. Adult unit leaders should review participants’ health histories and become knowledgeable about the medical needs of the youth members in their unit. This form is to be filled out by participants and parents or guardians and kept on file for easy reference. Part B is required with parts A and C for any event that exceeds 72 consecutive hours, a resident camp setting, or when the nature of the activity is strenuous and demanding, such as service projects, work weekends, or high-adventure treks. It is to be completed and signed by a certified and licensed health-care provider—physician (MD, DO), nurse practitioner, or physician’s assistant as appropriate for your state. The level of activity ranges from what is normally expended at home or at school to strenuous activity such as hiking and backpacking. Other examples include tour camping, jamborees, and Wood Badge training courses. It is important to note that the height/weight chart must be strictly adhered to if the event will take the unit beyond a radius wherein emergency evacuation is more than 30 minutes by ground transportation, such as backpacking trips, high- adventure activities, and conservation projects in remote areas. Risk Factors Based on the vast experience of the medical community, the BSA has identified that the following risk factors may define your participation in various outdoor adventures. • Excessive body weight • Asthma • Heart disease • Sleep disorders • Hypertension (high blood pressure) • Allergies/anaphylaxis • Diabetes • Muscular/skeletal injuries • Seizures • Psychiatric/psychological and emotional difficulties • Lack of appropriate immunizations For more information on medical risk factors, visit Scouting Safely on www.scouting.org. Prescriptions The taking of prescription medication is the responsibility of the individual taking the medication and/or that individual’s parent or guardian. A leader, after obtaining all the necessary information, can agree to accept the responsibility of making sure a youth takes the necessary medication at the appropriate time, but BSA does not mandate or necessarily encourage the leader to do so. Also, if state laws are more limiting, they must be followed. 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 (see Part C). 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 _____________________________________________ MEDICAL HISTORY Are you now, or have you ever been treated for any of the following: Allergies or Reactions to: Yes No Condition Explain Medication______________________________________ Asthma Food, Plants, or Insect Bites_______________________ Diabetes _________________________________________________ Hypertension (high blood pressure) Heart disease (i.e., CHF, CAD, MI) Stroke/TIA COPD Ear/sinus problems YesNoDateMuscular/skeletal condition ..Tetanus_____________________________ Menstrual problems (women only) ..Pertussis___________________________ Psychiatric/psychological and emotional difficulties ..Diptheria_ __________________________ Learning disorders (i.e., ADHD, ADD) ..Measles____________________________ Bleeding disorders ..Mumps_____________________________ Fainting spells ..Rubella_____________________________ Thyroid disease ..Polio_______________________________ Kidney disease ..Chicken pox_________________________ Sickle cell disease ..Hepatitis A_________________________ Seizures ..Hepatitis B_________________________ Sleep disorders (i.e., sleep apnea) ..Influenza ___________________________ GI problems (i.e., abdominal, digestive) .Exemption to immunizations claimed. Surgery Serious injury Other Immunizations: The following are recommended by the BSA. Tetanus immunization must have been receivedwithin the last 10 years. If had disease, put “D” and the year. If immunized, check the box andenter the year received(For more information about immunizations, aswell as the immunization exemption form, seeScouting Safely on Scouting.org.) 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 ________________________________________Medication ________________________________________Medication ________________________________________ Strength ___________ Frequency ___________________Strength ___________ Frequency ___________________Strength ___________ Frequency ___________________ Reason for medication___________________________Reason for medication___________________________Reason for medication___________________________ _____________________________________________________________________________________________________________________________________________________ Approximate date started _______________________Approximate date started _______________________Approximate date started _______________________ Temporary . Permanent .Temporary . Permanent .Temporary . Permanent . Medication ________________________________________Medication ________________________________________Medication ________________________________________ Strength ___________ Frequency ___________________Strength ___________ Frequency ___________________Strength ___________ Frequency ___________________ Reason for medication___________________________Reason for medication___________________________Reason for medication___________________________ _____________________________________________________________________________________________________________________________________________________ Approximate date started _______________________Approximate date started _______________________Approximate date started _______________________ Temporary . Permanent .Temporary . Permanent .Temporary . Permanent . NOTE: Be sure to bring medications in the appropriate containers, and make sure that they are NOT expired, including inhalers and EpiPens. You SHOULD NOT STOP taking any maintenance medication. Last Name: ___________________ DOB: ___________ Allergies: ___________ Emergency Contact No.: ________________________________ Part C Parental Informed Consent and Hold Harmless/Release Agreement I understand that participation in Scouting activities involves a certain degree of risk. I have carefully considered the risk involved and have given consent for myself or my child to participate in these activities. I understand that participation in these activities is entirely voluntary and requires participants to abide by applicable rules and standards of conduct. 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. 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. 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 to the adult in charge 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. . Without restrictions. . With special considerations or restrictions (list): ___________________________________________________________________________________________________________ Talent Release Form 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 by the Boy Scouts of America, and I hereby release the Boy Scouts of America 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. Participant’s name ____________________________________________________________________________________________ Participant’s signature _________________________________________________________________________________________ Parent/guardian’s signature _____________________________________________________________________________________ (if under the age of 18) Date _________________________________________________ Attach copy of insurance card (front and back) here. If required by your state, use the space provided here for notarization. Part C Last name: ________________________________ DOB: ______________________________