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Annual BSA Health Forms

Annual BSA Health Forms

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Published by pack24attleboro

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Published by: pack24attleboro on Apr 11, 2011
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01/30/2014

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High-adventure base participants:
Expedition/crew No.: __________________________________________________or sta position: _______________________________________________________
680-0012011 PrintingRev. 2/2011
Full name: _________________________________ DOB: ______________ Allergies: __________________ Emergency contact No.: ___________________
Annual BSA Health and Medical Record
Part A
GENERAL INFORMATION
Name ___________________________________________________________________ Date obirth ________________________________ Age _____________ Male FemaleAddress _________________________________________________________________________________________________________________________ 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 acilities or treatment)
_______________________ Religious preerence ______________________________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 o emergency, notiy: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 or any o the ollowing:
Allergies or Reaction to:Yes No Condition Explain
Medication ____________________________________Food, Plants, or Insect Bites __________________________________________________________________
Immunizations:
The ollowing are recommended by the BSA.
Tetanus immunization is required and must
have been received within the last 10 years.
Ifhad 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 _____________________Inuenza _______________________Other (i.e., HIB) ________________
 
Exemption to immunizations claimed(orm required).Asthma Last attack: ____________Diabetes Last HbA1c: ____________
Hypertension (high blood pressure)
Heart disease (e.g., CHF, CAD, MI)Stroke/TIALung/respiratory diseaseEar/sinus problemsMuscular/skeletal conditionMenstrual problems (women only)Psychiatric/psychological andemotional difcultiesBehavioral disorders (e.g., ADD,ADHD, Asperger syndrome, autism)Bleeding disordersFainting spellsThyroid diseaseKidney diseaseSickle cell diseaseSeizures Last seizure: ____________Sleep disorders (e.g., sleep apnea)Use CPAP: YesNoAbdominal/digestive problemsSurgerySerious injuryOther
MEDICATIONS
List all medications currently used. (I additional space is needed, please photocopythis part o the health orm.) Inhalers and EpiPen inormation must be included, eveni they are or occasional or emergency use only.
Medication _____________________________Strength ________ Frequency ____________Approximate date started ________________Reason or medication ___________________________________________________________Medication _____________________________Strength ________ Frequency ____________Approximate date started ________________Reason or medication ___________________________________________________________Medication _____________________________Strength ________ Frequency ____________Approximate date started ________________Reason or medication ___________________________________________________________Medication _____________________________Strength ________ Frequency ____________Approximate date started ________________Reason or medication ___________________________________________________________Medication _____________________________Strength ________ Frequency ____________Approximate date started ________________Reason or medication ___________________________________________________________Medication _____________________________Strength ________ Frequency ____________Approximate date started ________________Reason or medication ___________________________________________________________
Administration o the above medications is approved by (i required by your state):
________________________/ _______________________
Parent/guardian signature and/or MD/DO, NP, or PA signature
Be sure to bring medications in sufcient 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 sta position: _______________________________________________________
680-0012011 PrintingRev. 2/2011
Part B
INFORMED CONSENT AND HOLD HARMLESS/RELEASE AGREEMENT
I understand that participation in Scouting activities involves a certain degree o risk and can be physically, mentally, and emotionallydemanding. I also understand that participation in these activities is entirely voluntary and requires participants to abide by applicablerules and standards o conduct.In case o an emergency involving me or my child, I understand that every eort will be made to contact the individual listed as theemergency contact person. In the event that this person cannot be reached, permission is hereby given to the medical providerselected by the adult leader in charge to secure proper treatment, including hospitalization,
 
anesthesia, surgery, or injections omedication or me or my child. Medical providers are authorized to disclose protected health inormation to the adult in charge, campmedical sta, camp management, and/or any physician or health care provider involved in providing medical care to the participant.Protected Health Inormation/Confdential Health Inormation (PHI/CHI) under the Standards or Privacy o Individually IdentifableHealth Inormation, 45 C.F.R. §§160.103, 164.501, etc. seq., as amended rom time to time, includes examination
 
fndings, test results,and treatment provided or purposes o medical evaluation o the participant, ollow-up and communication with the
 
participant’sparents or guardian, and/or determination o the participant’s ability to continue in the program activities.I have careully considered the risk involved and give consent or mysel and/or my child to participate in these activities. I approvethe sharing o the inormation on this orm with BSA volunteers and proessionals who need to know o medical situations that mightrequire special consideration or the sae conducting o Scouting activities.I release the Boy Scouts o America, the local council, the activity coordinators, and all employees, volunteers, related parties, or otherorganizations associated with the activity rom any and all claims or liability arising out o 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 o America the right and permission to use and publish the photographs/ flm/videotapes/electronic representations and/or sound recordings made o me or my child at all Scouting activities, and I herebyrelease the Boy Scouts o America, the local council, the activity coordinators, and all employees, volunteers, related parties, or otherorganizations associated with the activity rom any and all liability rom such use and publication.I hereby authorize the reproduction, sale, copyright, exhibit, broadcast, electronic storage, and/or distribution o said photographs/ flm/videotapes/electronic representations and/or sound recordings without limitation at the discretion o the Boy Scouts o America,and I specifcally waive any right to any compensation I may have or any o the oregoing.Yes No
I understand that, if any information I/we have provided is found to be inaccurate, it may limit and/or eliminate the opportunityfor participation in any event or activity.
I I am participating at
Philmont, Philmont Training Center, Northern Tier, or Florida Sea Base:
I have also read andunderstand the risk advisories explained in Part D,
including height and weight requirements and restrictions,
and understandthat the participant will not be allowed to participate in applicable high-adventure programs i those requirements are not met.The participant has permission to engage in all high-adventure activities described, except as specifcally noted by me or thehealth-care provider.
Participant’s name _______________________________________________________________________________________________________Participant’s signature __________________________________________________________________ Date ____________________________Parent/guardian’s signature ______________________________________________________________ Date ____________________________
(i participant is under the age o 18)
Second parent/guardian signature ________________________________________________________ Date ____________________________
(i required; or 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 rom events:1. Name __________________________________________________________________________________________________________________2. Name __________________________________________________________________________________________________________________3. Name __________________________________________________________________________________________________________________
Part B Full name: ___________________________________________________________ DOB: __________________

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