Part A: Informed Consent, Release Agreement, and Authorization
Full name: ___________________________________________
Date of birth: _________________________________________
High-adventure base participants:
Expedition/crew No.: _______________________________________________
or staff position: ___________________________________________________
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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
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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)
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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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