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ARTLETT 2011

HIGH ADVENTURE LEADERS PACKET


LET THE ADVENTURE BEGIN

This manual was developed to help you plan So, begin planning today and keep
your Team or Crew’s week at Camp Bartlett reviewing your plan. Consult your crew
Scout Reservation this summer. We are members and find out what they hope to
convinced that if you follow the steps listed gain by their week at camp. Talk to their
in this Camp Leaders Program Guide to parents and find out what they would like
develop and plan your week at camp, your their sons to achieve.
camp experience will be much more
rewarding. Finally, talk to us so that we can help to
make it happen with you.
Although there are many ways to measure
the success of a week of camp, the real We stand prepared to help you do your best.
goals are those of the Scouting movement
itself: character building, citizenship Sincerely,
training, and personal fitness. The bottom
line is that the young man must enjoy
Jeremy Bell
himself and have fun.

The Council Camping Committee provides Camp Director


the right atmosphere; the staff will help to Jeremy.Bell@Scouting.org
make progress toward these goals, but
success depends mostly on you the Unit
Leader. It depends on your example,
imagination, preparation, and planning. The
challenge is great, but so are the rewards as
Scouting continues to turn boys into men.

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TIMETABLE
Use this timeline as a worksheet. Work with your unit’s committee and patrol
leader council to prepare for your week at camp.

October 1 Camp registration online


March Scoutmaster Orientation (location TBA)
16 weeks Parent’s night conducted to inform parents of camp plans
12 weeks Leadership arranged, two-deep leadership at all times
March 31 50% fees are due to the Trapper Trails Council, BSA
8 weeks Remind parents that all camp attendees need health forms
8 weeks Crew has personal equipment list
8 weeks Crew pre-camp swim checks (form attached)
8 weeks Customized unit T-shirts ordered (www.trappertrails.org)
4 weeks Health & medical record completed for each youth & adult
4 weeks All boys registered
4 weeks Transportation arranged and insurance verified
4 weeks Crew camping equipment ready
2 weeks Final camp fee amount due
1 week Unit roster verified at Council office (form attached)
1 week Tour permit filed at Council office (www.myscouting.org)
WHAT TO BRING
Below is a list of suggested items for your group to bring. Please note
additional information concerning High Adventure activities & supplies needed.

Flags Uniform
Wagon to move equipment to campsite Camera
Axe Compass
Bow saw Day pack
Paper & pencils Ground cloth
Thumb tacks Medical examination
Twine and rope Pillow
Trash bags Sleeping bag
Shovel Rain gear
Dish soap Spending money for trading post
Clorox Sun screen
Propane Swimsuit
Stoves Washable tableware (plate, bowl, cup, utensils)
Large pans for washing and rinsing dishes Towel & soap
Paper towels Canteen
Patrol box Mosquito spray
Aluminum foil Toilet paper
Pots, pans, griddles, dutch ovens, spatulas, spoons First Aid kit
Cooking items
Cooking oil
Backpack to carry personal gear to campsite
Venturing Handbook
OUTFITTING YOUR CREW

Every High Adventure participant needs: tent, backpack, day pack, sleeping
bag, water bottle, jacket/rain gear, hiking shoes, and water sandles.
THE CAMP WILL
PROVIDE...

Familiarize your crew with this equipment by planning your crew’s


pre-camp activities with GPS navigation, rappelling, and swimming!
LAND NAVIGATION ...

SHERMAN’S PEAK
“Southeastern
OLD EPHRAIM’S
Idaho’s talles t TT
TREE A R T LE
mountain PB
CAM E”
“ HO M
peak”
HUCKLEBERRIES
TOPOGRAPHY ...

Camp Bartlett - 6,500 feet above sea level


Sherman’s Peak - 9,692 feet above sea level

GET INTO SHAPE! Plan hikes as pre-camp activities to


get you and your boys in shape. This may be the most difficult, but
most rewarding hike, your crew has participated in!
TOPOGRAPHY ...

ARE YOU A SWIMMER? Encourage your boys to swim


before camp. Kayaking and rafting the Oneida Narrows will be an
event your boys will never forget!
INFORMATION
High Adventure Fees Tour Permits
The Trapper Trails Council Executive Board Every unit will need to file a tour permit with
has approved the following fee structure for their local Scout Service Center. A tour
the 2011 Boy Scout camping season: permit is attached to this leaders guide. After
completely filling in the permit, take it to the
$195 per youth Service Center to obtain an ID number.
$210 per youth out-of-council Units in the Trapper Trails Council may
$195 per adult choose to fax the tour permit in:
$210 per adult out-of-council
Ogden (801) 475-0197
Pre-camp Leaders Logan (435) 787-8278
Meeting Green River (307) 875-3754

All adult leaders are required to attend one Bring the tour permit to camp. This will be
of the two pre-camp leaders orientation needed during your unit check-in. As stated
meetings. You will learn about Camp on the tour permit, at least one adult is
Bartlett’s program and camping policies. required to be trained in Youth Protection.
This meeting is a great opportunity to ask
any questions you may have prior to camp. Unit Rosters
Location will be announced in March 2010.
All units will turn-in a unit roster during
check-in at camp. This roster is attached to
Refund Policy this leaders guide. List all adult leadership
and all youth that will be attending camp.
Camp fees are transferable to another Scout
up to the time of camp. These fees may not
Prior to arriving at camp, bring the roster to
be carried over to the following year. The
your local Scout Service Center. The office
unit may request a refund if a camper is
will verify that all participants are registered
unable to attend due to an illness/injury,
members of the Boy Scouts of America.
death in the family, or a personal emergency.
Out-of-council units, please have your roster
“No shows” will not be eligible for a refund.
verified by your local Scout Service Center.
Due to administrative costs, we will not
issue refunds for less than $25. Requests Contacting Camp
for a refund must be in writing, state
reason for refund, and be submitted to the Camp Bartlett is equipped with a relay phone
camp director before the unit leaves for emergencies only. The emergency
camp. There will be no refund requests number is (208) 963.9024..
accepted after the unit checks out of
camp. Mail may be sent to:
Camp Barlett (Unit #)
Refunds may be used as a transfer of at least PO Box 250
$100 for the next year camp reservation, Montpelier, ID 83254
pending approval of refund request.
Food is non-refundable.
Medical records will be turned-in during your unit check-in. Any
Uniform Inspection
prescriptions or medical concerns will need to be reported to the
A uniform gives a standard to meet, promotes group spirit and a camp’s medical officer upon arrival at camp.
sense of identity. It also designates equality among members of the Please note, many of the activities that are part of the High
group. Venturing crews have a greater latitude in uniforms than any Adventure program will take the unit beyond the radius wherein
other BSA family. Crews determine and design their own uniforms. emergency evacuation is more than 30 minutes by ground
Crews may also decide to create a troop shirt. Camp Bartlett shirts transportation.
are available to units that wish to create a uniformed look. Units Units will receive their medical records on the last day of camp,
that pre-order Camp Bartlett t-shirts are able to have their unit during check-out. Remember to make extra copies for your unit’s
number printed if ordered prior to camp. You will pick-up your records.
customized shirts upon arrival at camp.
Camp participants are required to wear closed-toe shoes when
Non Discrimination Statement
walking around camp. Sandals are only permitted at the waterfront
It is the policy of Camp Bartlett not to discriminate against any
area.
person on the basis of race, color, religion, creed, age, marital status
or any other legally protected characteristic in the administration of
any program. Camp Bartlett will endeavor, as far as practically
Crew Leadership applicable, to meet the needs of the disabled under direction the
Americans with Disabilities Act of 1990. Any Scout or leader with
All units must be under supervision of its own adult leaders. At a disability requiring the intervention of the camp staff should
least one leader must be a registered member of the Boy Scouts of contact the camp administration prior to attendance at summer
America. At least one leader must be 21 years of age or older. The camp.
second leader must be at least 18 years of age. We realize it is
sometimes difficult to find two-deep leadership for the week; Commissioner Service
however, we also feel that with advanced planning, constant two-
deep leadership can be arranged. While at camp, you will have a commissioner assigned to you.
Your commissioner will be available to answer your questions and
All visitors must check in at the camp office. No participants will
help you in any way possible. Your commissioner will be the one to
be released early from camp unless proper authorization is
help conduct the daily inspection of your campsite.
presented to the camp director or program director. No exceptions.

Medical Records
All participants of Camp Bartlett will be required to file a health
history with the camp medical officer. Youth and adults are
required to use the NEW health form.
Food Services Bikes
Any participants that have special dietary Mountain bikes (cycles of any kind) are not to
requirements are asked to notify Camp Bartlett be used in camp. If medical conditions require
two weeks prior to arrival at camp. the use of a bike for transportation, then
arrangements will be made.
High Adventure: Units participating in Camp
Bartlett’s high adventure program will receive Campfires
commissary as their food plan. Units will pick
Open campfires are permitted only in
up their food portions at the Commissary, and
designated campfire pits. Open flames may
cook them in their campsite. Food for
never be left unattended. In case of extreme
overnight or out-of-camp activities will be
fire danger, the US Forest Service and Camp
provided by the camp. Crews are responsible
Director reserve the right to prohibit open
to provide their own cooking equipment.
flames.
Ice is available from the commissary ($1 per
bag). Dogs
When washing dishes use hot water to wash all Absolutely no dogs or pets are allowed at
dishes. It is recommended to wash and rinse in Camp Bartlett.
an approved disinfectant after all meals. Allow
each dish to air dry. After drying, store in a Electronics
clean place. This will prevent diarrhea and
Participants are not allowed to bring electronic
other contact diseases.
devices to camp. Stereos, iPods, radios, and
Trading Post other devices are prohibited. These devices
distract from the wilderness experience.
The Trading Post has recently been expanded
to house many items for your pleasure. A Fire Prevention
variety of your favorite snacks and drinks are Camp Bartlett is located adjacent to US Forest
available for purchase, as well as camping Service property. It is critical that all
supplies, and souvenir items. regulations established by the BSA and US
A small amount of spending money is Forest Service are followed. Battery operated
encouraged. Please guide your crew members flash lights and lanterns are recommended for
in the amount of money to bring- usually $20- camp use. Absolutely no flames in tents.
$30 is more than enough. Each troop will be provided a fire guard chart,
which should be posted on the campsite
Quartermaster Supplies bulletin board. In the event of a fire, notify a
member of the camp staff immediately.
Equipment for camp beautification and
A fire drill will be conducted Monday night
conservations projects can be checked out from
during the flag ceremony.
the maintenance shed. All equipment must be
checked-out by the camp ranger. Axes, picks,
shovels, rakes, and saws may be checked out to
units. The maintenance shed is located just
north east of the office.
Only adults that are trained in chainsaw safety
are authorized to operate a chainsaw while in
camp (per National Camp Standards, 2011).

Buddy System
Encourage the youth in your crew to use the
buddy system at all times.
Firearms & Ammunition LP & Liquid Fuel Equipment
Boy Scouts are permitted to fire .22 caliber bolt action, single shot The use of propane, gas stoves, and lanterns is allowed under adult
rifles, air rifles and shotguns under the direction of a certified supervision. Refueling and lighting of this equipment must be done
instructor (National Standards, 2011). In keeping with this policy, by an adult.
all personal firearms and ammunition are prohibited at Camp
Bartlett. Parking & Vehicles
Knives are to be under 3 inches in length. No sheath knives are to Vehicles will be parked in designated parking areas upon arrival at
be allowed in camp. camp. No vehicles will be allowed to park near or in campsites. A
few handcarts are available to help transport your units equipment to
Firewood your campsite. We encourage units to bring their own wheelbarrow
to transport equipment.
There is plenty of dead wood located around Camp Bartlett. You are
free to use what you find. The cutting of live trees is prohibited. All The BSA prohibits passengers in the beds of trucks. All vehicles
campsites are equipped with an axe yard. Chopping of wood must driven to camp must be driven by a licensed driver older than 21
take place in the axe yard. years of age. All passengers must wear seat belts.
Do not remove standing trees without the approval of the camp Drug, Alcohol and Tobacco Use
director or camp ranger. Do not bring your own wood from home.
The Boy Scouts of America prohibits the use of alcoholic beverages
Fireworks and controlled substances at encampments or activities on property
owned and/or operated by the BSA, or at any activity involving
All fireworks are prohibited from National Forest property and
participation of youth members.
Camp Bartlett. Any person found with fireworks will be reported to
local law enforcement agencies and sent home. Adult leaders should support the attitude that young adults are better
off without tobacco and may not allow the use of tobacco products
Fishing at any BSA activity involving youth participants.

Participants wishing to fish at Camp Bartlett will need to obtain a Any adult wishing to smoke at Camp Bartlett may do so in the
Camp Bartlett fishing license. The license will allow the participant designated area set by the camp director.
to fish in Fife Lake for 5 days, with a limit of 2 fish per day. Youth found in possession of drugs, alcohol or tobacco will be
Licenses will be for sale at the Trading Post for $5. Pay attention to reported to local law enforcement agencies and sent home.
designated fishing areas- no fishing near the swimming or boating
waterfronts.

Garbage
Participants are asked to burn all paper products in their campsite,
recycle those products that are recyclable, and place all other items
in the trash bins located near the lodge.
Please help to keep camp looking nice by picking up litter and using
available trash cans.
Emergency Procedures Medications
Cloudburst & Heavy Rain All medications must be turned-in to the
Camps do experience minor flood conditions camp health officer upon arrival at camp.
due to extreme rains in a short period of time. Medications must be in their original
containers (Idaho State Law and National
Electrical Storms Standards, 2011).
In case of an electrical storm, participants
It is the responsibility of each Scout to make
should seek shelter off ridges and away from
sure they come to the camp health officer to
trees and other prominent objects.
receive their medications. All medications
High Winds will be kept by the camp health officer and
In the event of high winds, participants locked in the camp medical office. Asthma
should seek shelter inside the main lodge or inhalers and nitro glycerin pills are the only
sheltered program areas. exceptions- they are to be kept by the
individual.
Injuries or Illness
The camp health officer will be on duty at all
All treatments for injuries, illness, etc. will be
times. Serious injuries will be treated at Bear
performed in the health lodge by Camp
Lake Memorial Hospital in Montpelier,
Bartlett’s certified medical officer. On-the-
Idaho.
spot first aid will be given by qualified staff
members. Please report all injuries and
sickness to the camp medical officer.
Serious cases will be treated at Bear Lake
Memorial Hospital located in Montpelier,
Idaho.

Lost Camper
Should you realize someone is missing, report
this to the camp director immediately.
Include the following information:
• Full name and description of what the
person was wearing
• Where the person was last seen
• If the person was angry, homesick, and any
other details
• The persons favorite area of camp
• If the person’s tent or local latrine, showers,
and activity area have been checked
Shermans Peak for an overnighter- an
Fishing . . . our privately stocked lake awesome experience!
not far from your tent door! Enjoy fishing cut
throat, rainbow and brook trout.

Rock Climbing &


Kayaking . . . the Bear River!
GET READY FOR...

Explore
Rappelling . . . at the Paris Ice Caves.
and learn the basics of river dynamics,
Learn climbing techniques such as belaying,
reading river currents, and open-water
anchors, knots, and much more. Caving
kayaking instruction.
activities are also included.

Trap Shooting . . . with a 12 gauge Developing Leadership


shotgun.
Skills . . . such as planning, organizing,
Target Shooting . . . learn the ways decision-making, team-building,
of the wild-west by shooting black powder communicating, and achieving difficult goals.
muzzleloaders and archery.

GPS . . . navigation, map and compass,


and geocaching. You’ll learn expert skills in
backcountry camping and Leave No Trace as
you hike through rugged terrain to the top of
A R T LET T
SCOUT RESERVATION
To lower lake

Shotgun
Archery
To lower lake Range
Kodiak Silvertip Range

Old Ephraim Grizzly Three Toes

Showers
Rifle Range
Maintenance

Parking Office Ogden

Trading Post Clark


Boone
First Aid
Winnebago
Lewis Beckworth
Blackfoot

Scoutcraft Cody
Navajo Cody
Handicraft
Stewart
Iritaba
Lodge
Fremont
Apache Colter
Shawnee
Cherokee Carson

Laketown
L A K E F I F E Bridger
Seton
Fire Bowl Rendezvous
Crockett
Iriquois Fire Bowl
Seminole Pike
Parking
Nature Lodge
Smith
Seneca

Skintoe Bonneville
Lacota Swimming
Boating
Waterfront Johnson
Waterfront
Ute
Menomini
Sioux

Cortez
Shoshone Cortez
Showers Rockwell
Escalante
Nez Perce
Parking Coronado
Oneida
Entrance

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A R T LET T
HIGH ADVENTURE BASE
To Barchee’s Cabin
To main camp

ing
yak nt
Ka terfro
Wa

Trapper
(Staff Camp)
L A K E B E A R

Black
Diamond
Teewinot

Owen
White Water

Red Cliff

Sawtelle

Shermans

Fire Bowl
& Chapel

To main camp
& showers
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ARTLETT 2011 HIGH ADVENTURE
12
7:15 8:30 9:00 10:00 11:00 1:00 2:00 3:00 4:00 5:00 6:15 7:00 8:00 9:00 10:00
Noon

Fishing Instruction, Fire Drill & A


Mon Check-in, Swim checks, and Set-up camp Rappelling at Paris Ice Caves GPS Instruction and Flag Ceremony & s

D
Practice Campfire
t

L
r
F o
F
i
Tue Shermanʼs Peak Trek Shermanʼs Peak Trek l Shermanʼs Peak Trek n L
l
B i
a

u
o
g
a m g
r n y
g C h

n
Return from Shermanʼs Peak e John Colter Inter-troop activities
Wed O t
Kayak Instruction
e
Trek r Run

n
C e b s
a
m
e
c
s
o
r n Honor Trail e O
k e
Shooting
Thu Fishing Service Project Mile Swim & Shooting Sports y r u
e Sports

h
v t
f m a
o
r t

Fri
a n Kayak the Bear River
Kayak
Trip
Rendezvous Games
Check out with
Business Manager
Flag Ceremony &
Campfire
i
o
y
s n
s
t
Clean-up campsites & travel safely.
Sat Weʼll see you next year!

Schedule is subject to change!

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Trapper Trails Council
Unit Roster for Camps 2011
Unit # _____________ Sponsor _____________________ Campsite ____________________
Unit Leader’s Name ______________________________________
Street Address ____________________________________ State ______________________ ZIP ___________
Phone Number ____________________________________ Email _______________________________________

Youth & Adults that will be attending camp


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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, or when the
nature of the activity is strenuous and demanding, such as a high-adventure trek. Service projects or
work weekends may also fit this description. 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 limits 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.

For frequently asked questions about this Annual Health and Medical Record, see Scouting Safely online at
http://www.scouting.org/scoutsource/HealthandSafety.aspx. Information about the Health Insurance Portability
and Accountability Act (HIPAA) may be found at http://www.hipaa.org.
Annual BSA Health and Medical Record
Last name: ________________________________ DOB: ______________ Allergies: __________________ Emergency contact No.: ___________________
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 Reaction to:
Yes No Condition Explain Medication _______________________________________
Asthma Food, Plants, or Insect Bites ____________________
Diabetes ____________________________________________________
Hypertension (high blood pressure) Immunizations:
Heart disease (i.e., CHF, CAD, MI) The following are recommended by the BSA.
Stroke/TIA Tetanus immunization must have been received
COPD within the last 10 years. If had disease, put “D”
and the year. If immunized, check the box and
Ear/sinus problems
the year received.
Muscular/skeletal condition
Yes No Date
Menstrual problems (women only)
Tetanus ____________________________
Psychiatric/psychological and Pertussis __________________________
emotional difficulties
Diptheria __________________________
Learning disorders (i.e., ADHD, ADD)
Bleeding disorders Measles ___________________________
Fainting spells Mumps ____________________________
Thyroid disease Rubella ____________________________
Kidney disease Polio _______________________________
Sickle cell disease Chicken pox_______________________
Seizures Hepatitis A ________________________
Sleep disorders (i.e., sleep apnea) Hepatitis B ________________________
GI problems (i.e., abdominal, digestive)
Influenza __________________________
Surgery
Other (i.e., HIB) ___________________
Serious injury
Other Exemption to immunizations claimed.
MEDICATIONS (For more information about immunizations, as
List all medications currently used. (If additional space is needed, please photocopy well as the immunization exemption form, see
this part of the health form.) Inhalers and EpiPen information must be included, even Scouting Safely on Scouting.org.)
if they are for occasional or emergency use only.
Medication _____________________________ Medication _____________________________ Medication _____________________________
Strength ________ Frequency ____________ Strength ________ Frequency ____________ Strength ________ Frequency ____________
Approximate date started ________________ Approximate date started ________________ Approximate date started ________________
Reason for medication ___________________ Reason for medication ___________________ Reason for medication ___________________
________________________________________ ________________________________________ ________________________________________
Distribution approved by: Distribution approved by: Distribution approved by:
____________________ / ___________________ ____________________ / ___________________ ____________________ / ___________________
Parent signature MD/DO, NP, or PA Signature Parent signature MD/DO, NP, or PA Signature Parent signature MD/DO, NP, or PA Signature
Temporary Permanent Temporary Permanent Temporary Permanent
Medication _____________________________ Medication _____________________________ Medication _____________________________
Strength ________ Frequency ____________ Strength ________ Frequency ____________ Strength ________ Frequency ____________
Approximate date started ________________ Approximate date started ________________ Approximate date started ________________
Reason for medication ___________________ Reason for medication ___________________ Reason for medication ___________________
________________________________________ ________________________________________ ________________________________________
Distribution approved by: Distribution approved by: Distribution approved by:
____________________ / ___________________ ____________________ / ___________________ ____________________ / ___________________
Parent signature MD/DO, NP, or PA Signature Parent signature MD/DO, NP, or PA Signature Parent signature MD/DO, NP, or PA Signature
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.
Part B
PHYSICAL EXAMINATION
Height ____________ Weight ____________ % body fat ___________ Meets height/weight limits Yes No
Blood pressure ___________ Pulse ____________
Individuals desiring to participate in any high-adventure activity or event in which emergency evacuation would take longer
than 30 minutes by ground transportation will not be permitted to do so if they exceed the height/weight limits as documented
in the table at the bottom of this page or if during a physical exam their health care provider determines that body fat
percentage is outside the range of 10 to 31 percent for a woman or 2 to 25 percent for a man. Enforcing this limit is strongly
encouraged for all other events, but it is not mandatory. (For healthy height/weight guidelines, visit www.cdc.gov.)

Explain Any Explain Any


Normal Abnormal Range of Mobility Normal Abnormal
Abnormalities Abnormalities
Eyes Knees (both)
Ears Ankles (both)
Nose Spine
Throat
Lungs Other Yes No
Heart Contacts
Abdomen Dentures
Genitalia Braces
Skin Inguinal hernia Explain
Emotional Medical equipment
adjustment (i.e., CPAP, oxygen)
Tuberculosis (TB) skin test (if required by your state for BSA camp staff) Negative Positive
Allergies (to what agent, type of reaction, treatment): __________________________________________________________________________________________
______________________________________________________________________________________________________________________________________________________

I certify that I have, today, reviewed the health history, examined this person, and approve this individual for participation in:
Hiking and camping Competitive activities Backpacking Swimming/water activities Climbing/rappelling
Sports Horseback riding Scuba diving Mountain biking Challenge (“ropes”) course
Cold-weather activity (<10°F) Wilderness/backcountry treks
Specify restrictions (if none, so state) ____________________________________________________________________________________________________________
________________________________________________________________________________________________________________________
Certified and licensed health-care providers recognized by the BSA to perform this exam include physicians (MD, DO), nurse
practitioners, and physician’s assistants.

To Health Care Provider: Restricted approval includes: Provider printed name ______________________________________________________
➔ Uncontrolled heart disease, asthma, or hypertension.
Signature _______________________________________________________________________
➔ Uncontrolled psychiatric disorders.
➔ Poorly controlled diabetes. Address ________________________________________________________________________
➔ Orthopedic injuries not cleared by a physician. City, state, zip _________________________________________________________________
➔ Newly diagnosed seizure events (within 6 months).
➔ For scuba, use of medications to control diabetes, asthma, Office phone __________________________________________________________________
or seizures. Date _____________________________________________________________________________
Height Recommended Allowable Maximum Height Recommended Allowable Maximum
(inches) Weight (lbs) Exception Acceptance (inches) Weight (lbs) Exception Acceptance
60 97-138 139-166 166 70 132-188 189-226 226
61 101-143 144-172 172 71 136-194 195-233 233
62 104-148 149-178 178 72 140-199 200-239 239
63 107-152 153-183 183 73 144-205 206-246 246
64 111-157 158-189 189 74 148-210 211-252 252
65 114-162 163-195 195 75 152-216 217-260 260
66 118-167 168-201 201 76 156-222 223-267 267
67 121-172 173-207 207 77 160-228 229-274 274
68 125-178 179-214 214 78 164-234 235-281 281
69 129-185 186-220 220 79 & over 170-240 241-295 295
This table is based on the revised Dietary Guidelines for Americans from the U.S. Dept. of Agriculture and the Dept. of Health & Human Services.

Part B Last name: _________________________________________ DOB: ___________________


Part C
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 and/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 Protected Health Information/
Confidential Health Information (PHI/CHI) under the Standards for Privacy of Individually Identifiable Health Information, 45 C.F.R.
§§160.103, 164.501, etc. seq., as amended from time to time, including 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) ____________________________________________________________________________________________
____________________________________________________________________________________________________________________________________________________

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 the event: (You must Adults NOT authorized to take youth to and from the event:
designate at least one adult. Please include a telephone number.)
1. _____________________________________________________________________ 1. _____________________________________________________________________
2. _____________________________________________________________________ 2. _____________________________________________________________________
3. _____________________________________________________________________ 3. _____________________________________________________________________
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.

SKU 34605
BOY SCOUTS OF AMERICA
1325 West Walnut Hill Lane
P.O. Box 152079
Irving, Texas 75015-2079 7 30176 34605 2
http://www.scouting.org
34605 2009 Printing

Part C Last name: _________________________________________ DOB: ___________________


Rev. 9/2009

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