Part A: Informed Consent, Release Agreement, and Authorization
Full name: ___________________________________________
Date of birth: _________________________________________
High-adventure base participants:
Expedition/crew No.: _______________________________________________
or staff position: ___________________________________________________
2019 Printing
Adults NOT Authorized to Take Youth to and From Events:
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.
Every person who furnishes any BB device to any minor, without the express or implied permission
of the parent or legal guardian of the minor, is guilty of a misdemeanor. (California Penal Code
Section 19915[a]) My signature below on this form indicates my permission.
I give permission for my child to use a BB device. (Note: Not all events will include BB devices.)
Checking this box indicates you DO NOT want your child to use a BB device.
List participant restrictions, if any: None
Complete this section for youth participants only:
Adults Authorized to Take Youth to and From Events:
You must designate at least one adult. Please include a phone number.
Name: _________________________________________________________________
Phone: _________________________________________________________________
Name: _________________________________________________________________
Phone: _________________________________________________________________
Name: _________________________________________________________________
Phone: _________________________________________________________________
Name: _________________________________________________________________
Phone: _________________________________________________________________
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 Scout Ranch, Philmont Training Center, Northern Tier, 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)
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.
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Part B1: General Information/Health History
Full name: ___________________________________________
Date of birth: _________________________________________
High-adventure base participants:
Expedition/crew No.: _______________________________________________
or staff position: ___________________________________________________
In case of emergency, notify the person below:
Name: ______________________________________________________________________________Relationship: ___________________________________________________
Address: _________________________________________________________________ Home phone: _________________________ Other phone: _________________________
Alternate contact name: _________________________________________________________________ Alternate’s phone: ______________________________________________
Age: ____________________________ Gender: __________________________ Height (inches): ___________________________ Weight (lbs.): ____________________________
Address: _________________________________________________________________________________________________________________________________________
City: ___________________________________________State: ____________________________ ZIP code: __________________ Phone: ______________________________
Unit leader: ____________________________________________________________________________ Unit leader’s mobile #: _________________________________________
Council Name/No.: _______________________________________________________________________________________________________Unit No.: ____________________
Health/Accident Insurance Company: ________________________________________________________ Policy No.: ___________________________________________________
Health History
Do you currently have or have you ever been treated for any of the following?
Yes No Condition Explain
Last HbA1c percentage and date: Insulin pump: Yes £ No £
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.
Asthma/reactive airway disease
Last attack date:
Lung/respiratory disease
Ear/eyes/nose/sinus problems
Muscular/skeletal condition/muscle or bone issues
Head injury/concussion/TBI
Altitude sickness
Psychiatric/psychological or emotional difculties
Neurological/behavioral disorders
Blood disorders/sickle cell disease
Fainting spells and dizziness
Kidney disease
Seizures or epilepsy
Last seizure date:
Abdominal/stomach/digestive problems
Thyroid disease
Skin issues
Obstructive sleep apnea/sleep disorders
CPAP: Yes £ No £
List all surgeries and hospitalizations
Last surgery date:
List any other medical conditions not covered above
2019 Printing
Please attach a photocopy of both sides of the insurance card. If you do not have medical insurance, enter “none” above.
Part B2: General Information/Health History
Full name: ___________________________________________
Date of birth: _________________________________________
High-adventure base participants:
Expedition/crew No.: _______________________________________________
or staff position: ___________________________________________________
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)
Please list any additional information about your
medical history:
Review for camp or special activity.
Reviewed by: ___________________________________________
Date: _________________________________________________
Further approval required:
Yes No
Reason: _______________________________________________
Approved by: ____________________________________________
Date: _________________________________________________
AUTOINJECTOR? Exp. date (if yes) ___________________________
INHALER? Exp. date (if yes) ___________________________________
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 list on a separate sheet and attach.
Medication Dose Frequency Reason
The following immunizations are recommended. 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.
Yes No Had Disease Immunization Date(s)
Chicken Pox
Hepatitis A
Hepatitis B
Other (i.e., HIB)
Exemption to immunizations (form required)
2019 Printing
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.
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Part C: Pre-Participation Physical
This part must be completed by certied and licensed physicians (MD, DO), nurse practitioners, or physician assistants.
Full name: ___________________________________________
Date of birth: _________________________________________
High-adventure base participants:
Expedition/crew No.: _______________________________________________
or staff position: ___________________________________________________
Please ll in the following information:
Yes No Explain
Medical restrictions to participate
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):
True False Explain
Meets height/weight requirements.
Has no uncontrolled heart disease, lung disease, 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 planning to scuba dive, does not have diabetes, asthma, or seizures.
Examiner’s signature: _______________________________________ Date: _______________
Examiner’s printed name: _________________________________________________________
Address: _______________________________________________________________________
City: ______________________________________State: ______________ ZIP code: _________
Ofce phone: ___________________________________________________
Normal Abnormal Explain Abnormalities
Skin issues
Yes No Allergies or Reactions Explain Yes No Allergies or Reactions Explain
Medication Plants
Food Insect bites/stings
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Height (inches) Weight (lbs.) BMI Blood Pressure Pulse
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,
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. You can also visit to view this information online.
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October 2019
Sea Base Experience. Sea Base adventures are not risk-free.
Participants must follow safety measures and take personal responsibility for
their health and safety. Climate conditions include temperatures ranging from 45
to 95 degrees, high humidity, heat indexes reaching 110 degrees, and frequent,
sometimes severe tropical weather. Prolonged, rigorous activities include
snorkeling, scuba diving, kayaking, canoeing, sailing, hiking, and others.
It is the responsibility of participants, participant parents or guardians,
participant health-care teams, and unit leaders to see that each individual
youth or adultcan safely take part in Sea Base adventures.
Adult Participants. It is the role of accompanying adults to
ensure youth safety. Because of this, adult participants must arrive in good
physical condition and have no medical conditions that could result in diverting
the Sea Base staff’s attention away from youth participants.
Sea Base participants must be able to
Swim in a strong manner
Climb a 6-foot ladder, unassisted, in inclement weather, from the water
onto a rocking vessel
Self-rescue if found overboard in inclement weather
Location. Sea Base adventures are conducted at sea, often far from
land, with limited access to emergency services. Response times can be
affected by weather, seas, and location, and can be delayed for hours.
Individuals with medical conditions that require immediate or nearly immediate
access to professional medical care should not attend Sea Base.
Right to Refuse. Sea Base reserves the right to deny participation
based on health and safety concerns and/or medical history.
Special Needs or Medical Concerns. Any individual
with special needs or medical concerns must have an onsite advocate who
understands the individual’s condition and treatment and who is prepared to
provide support to the individual.
Trained Leadership. Each crew is required to have at least
one adult who is trained in wilderness first aid and CPR or has a greater
professional medical certification. This leader acts as the primary first response
until emergency services arrive. There are no on-site facilities for treatment or
extended care at Sea Base. Sea Base does not staff professional
medical personnel.
Medications. Individuals requiring medication should continue
medications as prescribed and bring an appropriate supply. Each crew must
develop a plan to secure, lock, and dispense medication.
Allergies. Participants with allergies that may result in severe reactions
or anaphylaxis should bring an adequate supply of epinephrine auto-injectors
(EpiPen) to last up to three hours.
Recommendations Regarding
Chronic Illness and/or Compromised
Immune System. Persons with chronic conditions and/or
compromised immune systems should seek medical advice and education
regarding medical risks associated with harsh marine environments before
participating. Individuals with open wounds or who are at risk for chronic
illnesses or immune disorders should not attend Sea Base.
Hypertension (High Blood Pressure). Participants
should have a blood pressure less than 140/90. Individuals with hypertension
should have the condition treated and well-controlled before attending.
Insulin-Dependent Diabetes Mellitus. Diabetes
must be well-controlled. Hypoglycemia can lead to unconsciousness
and drowning.
Insulin-dependent persons who have been newly diagnosed or who have
undergone changes in delivery systems in the last six months are advised
not to participate.
Persons with diabetes who have had frequent problems and/or
hospitalizations should not participate.
Persons using insulin to control diabetes will not be permitted to
scuba dive.
Any HbA1c test greater than 7 in the previous 12 months disqualifies a
person from scuba diving.
Persons under the age of 18 who control their diabetes with exercise
and diet (without the aid of medication) and can provide three sequential
hemoglobin tests with HbA1c values less than 6 may be approved to
scuba dive.
Persons over the age of 18 who control their diabetes with exercise and
diet (without the aid of medication) and can provide four HbA1c tests,
each with a value less than 7, within the previous 12 months may be
approved to scuba dive.
Seizures (Epilepsy). Seizures while snorkeling or scuba diving
are extremely dangerous and often fatal.
History of loss of consciousness often precludes snorkeling or scuba
diving. Formal consultation with a neurologist and/or cardiologist is
No participant with a history of seizures or taking anti-epileptic
medication may snorkel or scuba dive.
Prospective participants with a history of infant febrile seizures
may be considered for snorkeling or diving after formal
consultation with a neurologist.
Asthma. Asthma must be well-controlled. Persons requiring use of
medication and/or an inhaler must bring an ample supply.
Persons being treated for asthma (including reactive airway disease)
are disqualified from scuba diving.
Persons with a history of asthma who have been asymptomatic and have
not used medications to control asthma for five years or more may be
allowed to scuba dive if resolution of asthma is specifically confirmed
by their physician and includes provocative pulmonary function testing
conducted by a pulmonologist.
Provocative testing can include exercise, hypertonic saline, a
hyperpnea test, etc.
Phone: 305-664-4173 Website:
High-Adventure Risk Advisory to
Health-Care Providers and Parents
Florida Sea Base
October 2019
Recent Musculoskeletal Injuries and
Orthopedic Surgery. Persons with musculoskeletal problems or
orthopedic surgeries within the last six months must provide a letter from their
treating physician to participate.
Psychological and Emotional Difficulties.
Any condition should be well-controlled without the services of a mental health
practitioner. Participants requiring medication must bring an ample supply and
take as prescribed for the duration of their trip.
Many psychotropic medications are not compatible with scuba diving.
Persons taking more than one psychotropic medication will not be
cleared to scuba dive.
Persons with anxiety will not be cleared to scuba dive.
Weight Limits. Participants must meet BSA height and weight
guidelines. Exceptions may be made for individuals who do not exceed the BSA
height and weight guidelines by more than 20 pounds. Due to rescue equipment
weight restrictions, individuals who are 78 inches (6.5 feet) and taller cannot be
offered an exception.
Scuba Participants. Persons with conditions listed as severe
by the Recreational Scuba Training Council (RSTC) will not be permitted to
scuba dive. Persons with conditions prohibited by BSA scuba policy will not be
permitted to scuba dive. Various risk factors may exclude a person from scuba
diving, either temporarily or permanently. Risk factors include, but are not limited
to, ear and sinus problems, recent surgery, spontaneous pneumothorax, asthma
or reactive airway disease, seizure disorders, diabetes, leukemia, sickle-cell
disease, pregnancy, panic disorders, active psychosis, certain medications,
and narcolepsy.
Closing. Sea Base, BSA is an industry leader in maritime adventures with
an excellent safety record. If you have questions regarding medical policies,
medical concerns, or medical approval, please contact Sea Base at
Phone: 305-664-4173 Website:
High-Adventure Risk Advisory to
Health-Care Providers and Parents
Florida Sea Base