Annual BSA Health and Medical Record Part A GENERAL INFORMATION

Transcription

1 Full name: DOB: Allergies: Emergency contact No.: Annual BSA Health and Medical Record Part A GENERAL INFORMATION T-Shirt Size: Child: Small Medium Large Adult: Small Medium Large XL 2-XL 3-XL Name Date of birth Age Male 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 Asthma Diabetes Last attack: Last HbA1c: Food, Plants, or Insect Bites Hypertension (high blood pressure) Heart disease (e.g., CHF, CAD, MI) Stroke/TIA Immunizations: The following are recommended by the BSA. Tetanus immunization is required and must have been received within the last 10 years. If Lung/respiratory disease had disease, put D and the year. If immunized, Ear/sinus problems check the box and the year received. Muscular/skeletal condition Yes No Date Menstrual problems (women only) Tetanus Psychiatric/psychological and Pertussis emotional difficulties Diphtheria Behavioral disorders (e.g., ADD, ADHD, Asperger syndrome, autism) Measles Bleeding disorders Mumps Fainting spells Rubella Thyroid disease Polio Kidney disease Chicken pox Sickle cell disease Hepatitis A Seizures Last seizure: Hepatitis B Influenza Other (i.e., HIB) 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. Female Exemption to immunizations claimed (form required). (For more information about immunizations, as well as the immunization exemption form, see Scouting Safely on Scouting.org.) Administration of the above medications is approved by (if required by your state): / Parent/guardian signatureand /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 Printing Rev. 2/2011

2 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 , , 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 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 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. Part B Full name: DOB: Printing Rev. 2/2011

3 WHITE EAGLE DISTRICT CUB SCOUT DAY CAMP STAFF AGREEMENT Name: Address (street, city, zip): Age: Date of Birth: Phone: Pack# Current Registered Position: CPR Certified: Yes No Certifying Organization: CPR Expiration Date: Youth Protection Training Date: First Aid: Yes No Are you: Physician RN LPN Physician s Assistant Medical Student Paramedic EMT Other What position(s) do you want to work in? Den Walker Tuesday Session Leader Tuesday Where? Den Walker Wednesday Session Leader Wednesday Where? Den Walker Thursday Session Leader Thursday Where? Den Walker Friday Session Leader Friday Where? Den Walker Saturday Session Leader Saturday Where? Den Chief Training Date: Age: Circle Days you will work: M T W TH F S If you have not attended Den Chief, NYLT training you will need a letter from your Scoutmaster and approval from the Camp Director prior to being accepted as a Den Chief. If accepted as a staff member, you will be expected to fulfill the following requirements: Attend Training. Make sure safety procedures and BSA standards are followed at all times. Conduct yourself in a Scout-like manner at all times. Help setup your program area (Session Leader). Plan program activities (Session Leader). Help instruct and guide the Scouts (Session Leader). Provide supervision of the Scouts throughout the day (Den Walkers). Make sure the Scouts use the buddy system when away from their den or activity (Den Walkers). Assist the Scouts and Leaders at each session (Den Walkers). Bring a sack lunch daily. Beverage will be provided (NO soda). Help out as necessary when asked by the Camp Director or Program Director. Submit an evaluation of your area and camp operation. Your Signature: Date

4 2012 White Eagle Day Camp Webelos Scout Overnight The Webelos Scout overnight that follows day camp is an experience for ALL Webelos Scouts with an adult partner age 21 or older that is a parent or guardian. It is an opportunity for the Scout and his partner to experience, possibly, his first camping event. Partners are only permitted in tents with their own scout. A partner can be responsible for up to 2 scouts. In the event a Scout is not the adult partners child, other tent/sleeping arrangements must be made. Following camp on Friday afternoon, the Webelos Scout and his adult partner will begin the Webelos Scout overnight. Campsites will be assigned on Friday afternoon following camp. No reservations will be made. This form will help planning for this event. At the end of Day Camp, the campsite assignments will be posted for your designated campsite. Supplies: Please review the Webelos Scout handbook for an extensive list of supplies. You will not need most of them. Below are suggestions for supplies: Your own tent A sleeping bag Pajamas (keeps the bugs away) Outdoor clothes (we will camp out rain or shine) Flashlight & extra batteries Personal hygiene supplies Hat for shade Mess kit and eating utensils Extra shoes (closed toed) and extra socks (dry feet are happy feet) Wagon to transport supplies to and from campsite. Shovel and pail for fire safety There will be NO privately owned vehicles DRIVING to the campsites. Please contact the Day Camp Director to make any arrangements if there are health concerns traveling to the campsite. All adult partners must have a health form on file in case of an emergency.

5 2012 Webelos Scout Overnight Return this form and the health form to your Pack Coordinator PLEASE PRINT Webelos Scout name: Pack: City: Adult Partner name: (must be over 21) Relation to Scout: Emergency contact: Name: Phone:

6 White Eagle District Day Camp 2012 Kiddie Korral Registration Form Name: Age: Parents: Pack # EMERGENCY CONTACT: Name: Phone number: Please Circle Days Attending: Tues Wed Thurs Fri Kiddie Korral Fees: (includes T-shirt) 1 Day... $ Days... $ Days... $ Days... $10.00 If a registered Scout is attending Day Camp, this Kiddie Korral form and the Day Camp form are required. There are NO additional fees.