Time Traveler
Day Camp 2015
Leader Guide and Registration Packet
Please register early!!
Registration is first come, first serve.
Maximum 135 scouts per camp, then the camp will be full and closed.
Get your forms in early to get your first choice Camp!
Ore-Ida Council Boy Scouts of America
8901 W. Franklin Road
Boise, Idaho 83709
Phone: 208-376-4411
Fax: 208-376-4884
1
How to register
1- Complete Pack Registration Form
•Provide email and phone numbers to ensure communication with camp staff.
•All scouts must be registered with Ore-Ida Council prior to camp.
•All scouts and adults must have the Annual BSA Health and Medical Form, 2014
printing, parts A and B filled out and turned in at registration. (see link)
•One BSA registered adult must complete Youth Protection Training (YPT) prior to
camp.
2- Take Registration Form, Health Forms, and payment to Council Office
•Registration is first come, first serve
•Pack registration does not guarantee a placeholder for late registrants, even from
the same pack
•All payments must be made at the time of registration. No exceptions.
•All scouts and adults must have a completed Health Form at time of registration.
•One-day camps are for Cubs and Webelos. Two-day camps are WEBELOS only.
Fees
•One-day fees are $30 per scout before 5pm on April 8, 2015, and $35 thereafter.
•Two-day fees are $45 per scout before 5pm on April 8, 2015, and $50 thereafter.
•Gold Card packs receive a $5 discount per scout.
•Fees are transferable, but not refundable.
•Make checks payable to: BSA
Important Information
Tour and Activity Plan must be submitted to the scout office by each Pack, 21 days
prior to camp.
Camp fees include Camp t-shirt, participation patch and all materials for each scout.
Additional Camp t-shirts for leaders are available for $10 and adults 2XL and up for
$12 each. Please order early to ensure correct size.
Questions? Contact the Camp Director for the camp you wish to attend.
Please fill out forms completely before bringing them to the Council Office:
Ore-Ida Council Boy Scouts of America
8901 W. Franklin Road, Boise, Idaho 83709
3
Who may attend Day Camp?
All Scouts must be registered with the Ore-Ida Council, Boy Scouts of America and
submit a completed current BSA Health and Medical Record, parts A and B only (see
link) at registration. If you are unsure whether a Scout is registered, contact the
Scout Office at 376-4411.
All volunteers must complete the BSA Health and Medical Record form, parts A and
B only (see link), and one BSA registered adult must complete Youth Protection
Training prior to camp (see link.)
Volunteers are welcome and needed to run a successful camp. Pack Leaders, Den
Leaders, Parents, Guardians, adult family members and mature youth are encouraged to volunteer! We highly encourage all adults to take the online Youth Protection Training prior to attending camp. Please contact the camp director for more details. A wristband will be provided at check-in to all adults for identification purposes.
Choose a Camp
Your pack may choose to attend ANY camp. Consider the date
and location to determine which is best for your boys and leadership. One-day camps are designed for Tiger, Wolves, Bears and
Webelos scouts. Two-day camps are designed for Webelos only.
Bear Cubs who will become Webelos during the summer may attend the two-day camps. Camps fill quickly, so sign up early to get
the camp you want. Camps will be full and closed at 135 scouts.
Attending
Walking
Scouts
Leaders
1-10————————2
11-15———————-3
16-20———————-4
21-25———————-5
26-30———————-6
**Pack registration is not a placeholder for late registrants, even from
the same pack.**
Camps will close at 135 scouts.
Pack Number
Everything at camp is organized by pack number. You will need your pack number
to register, pick up t-shirts and to check in at camp. Please be sure that everyone
attending camp knows your pack number.
Pack Contact Person
We highly recommend that someone in your pack be First Contact Person— in charge
of collecting health forms, receiving and passing along information, and attending
camp orientation. This person needs to be a reliable adult with an e-mail address
and phone number. Please provide a Second Contact, so camp staff can ensure your
pack receives important information and reminders.
What about Webelos Woods?
If you are a WEBELOS Leader, check out Webelos Woods! Day camp and Webelos
woods will compliment each other. You can go to both and get a whole new set of
achievements!!! How exciting is that?
4
What is a Walking Leader?
A walking leader is an adult who walks from station to station, staying with the
scouts during the day at camp. Your duty is to directly supervise your boys at camp,
including:
- Check in yourself and your scouts at the Registration area. Verify attendance and
make sure all forms are complete and accurate. For 2-day camps, you must verify
attendance BOTH days
- Enforce the buddy system
- Provide discipline for your pack
- Escort your scouts to each station, and assist with activities
- Keep track of possible achievements for each boy (a list will be provided for each
pack)
- Plan transportation to and from camp
- Supervise your scouts during lunchtime
- Communicate with Camp Staff
- Help the scouts keep track of their belongings
- Be cheerful with all types of personalities you will meet during the day :)
Each pack must have 2 adults (18+) for up to 10 scouts, and one additional adult for
each additional 1-5 scouts. Den Chiefs do not qualify as walking leaders, but we
would love to see them at camp. One adult must be registered as a leader and have
completed Youth Protection Training (see link.)
THANK YOU for your time and positive attitude!
Fees
Camp fees paid before April 8, 2015 are $30.00 for one-day camps, and $45.00 for
two-day camps. After April 8th, fees go to $35 (1-day) and $50 (2-day). Gold card
Packs will receive a $5 discount per scout. Fees are charged at the end of the business day. All payments are due at the time of registration.
Fees include a camp t-shirt, camp participation patch, and all materials for the boys.
We only purchase enough materials for paying Scouts. There will not be enough for
adults or others to make the projects. There is no fee for volunteers, but camp tshirts are available for $10, and adults 2XL and up for $12 each. Please order at
time of registration to ensure the correct size is available.
Refund Policy
It is the policy of the Ore-Ida Council that all fees are transferable, but not refundable. Changes must be made 5 business days prior to your camp or the camp you
wish to attend. The Council must commit financial resources to make Day Camp
possible. Therefore, you are expected to attend camp on the date you selected.
5
Forms, Forms, Forms
Health and Medical Record— EVERYONE at camp (scouts, parents, leaders, volunteers, etc) must complete a current BSA Health and Medical Record form, parts A
and B (see link.) The doctor’s physical and insurance card are NOT required. This is
a National BSA Standard Requirement. Youth Volunteers/Den Chiefs (under age 18)
must have a parent/guardian’s signature on their completed form.
In the event of an emergency, we need these forms to give to medical personnel.
Even if you have a Health and Medical Record on file at the Scout office or with your
Pack, we need to have an additional copy at camp. Photocopies are acceptable. All
Health and Medical Record forms are returned at the end of camp, or destroyed.
Medical Awareness
This box on the registration form is to inform Camp Staff of any conditions we need
to know about (medications at camp, life-threatening allergies, ADD/ADHD, autism,
other health conditions, hearing aids, wheelchairs, etc.) Please write “Yes” in the
box and we will check the Health and Medical Record form for more information.
Sudden conditions, such as a broken bone in a cast , can be added at camp. ALL
medications at camp need to be in the original containers, labeled with name and
pack number, to turn over to the Health Officer at check-in. The Health Officer will
dispense medications as required. For legal and safety reasons, Pack leaders are not
allowed to dispense medications.
Rescue inhalers and Epi-pens may remain with walking leaders, but must be reported to the Health Officer. We want your scouts and leaders to be safe and healthy at
camp.
Two-Deep Leadership- Two-deep leadership on all outings is required. Two registered adult leaders, or one registered leader and a parent of a participating Scout or
other adult, one of whom must be 21 years of age or older, are required for all trips
and outings.
Youth Protection Training— One BSA registered adult must complete Youth Protection Training (YPT) prior to camp (see link.) We highly encourage all adults to take
the online Youth Protection Training prior to attending camp.
Tour and Activity Plan— Each Pack must submit a Tour and Activity Plan to the
Scout Office, 21 days prior to camp (see Link.) You can file the Tour and Activity
Plan early, so do it now! Only one plan is required per Pack, even if you arrive in
separate vehicles. A copy of the approved Tour and Activity Plan must accompany
your Pack at camp.
Label ALL belongings with Name
and Pack number
6
Transportation
Transportation is the responsibility of each Pack. Whether you plan to carpool or
meet at camp, please follow these guidelines so everyone arrives safely:
Make sure everyone knows what your Pack’s plan is, especially for 2-day camps.
Parents, Leaders and Scouts need to know where to meet, what time and how
they are getting home.
Use caution and stay alert in Risk Zones (entrances, exits and parking areas)
All Scouts and volunteers must wear seat belts when riding in any vehicle. If your
child cannot fasten their own seat belt, you must inform the driver.
Scouts are not allowed to travel in the backs of trucks or campers.
File your Tour and Activity Plan early to the Scout Office
Orientation Meeting
Adults who are going to camp must attend orientation meeting. You will meet Camp
staff, learn about the camp you are attending, ask questions and pick up camp tshirts for your Pack. Please attend the correct orientation for the Camp you are attending. See the 2015 Day Camp Schedule for details.
Arriving at Camp
Check-in begins at 8:30 am. Please arrive on time. Opening Ceremonies will be
promptly at the time specified for your camp. A gathering activity will be available
for the scouts.
1. When you locate the check-in area, designate one adult to check in your Pack.
This person will:
A. Verify Scouts’ attendance. Scouts without completed forms
and payment cannot stay at camp.
B. Verify Leaders’ attendance. If adults attending are different
than the adults listed on the original registration form,
they must have a completed Health and Medical Record
form, and one must be a BSA registered adult and have
completed Youth Protection Training. Please bring forms
already filled out.
C. —All adults will be required to wear a wristband to show that
they are checked in.
—EVERYONE must check-in with camp staff. Even if you are a
parent dropping off a forgotten lunch (or something else) you
must come to the check-in area first. We will assist you in finding your scout. Please respect this policy. Camper safety is
top priority.
2. The other adults can proceed to the gathering area with the scouts. Each Pack
will be put into groups to visit each station. Larger packs may be split into two
groups, and smaller packs may be combined with other packs to keep the groups
balanced. This is one reason why additional leaders are needed.
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What to Bring • Camp T-shirt, this is the uniform at
camp
• Refillable water bottle
• Sturdy shoes that can get wet
• NO open toed shoes, flip flops or crocs
• Sack lunch and something to store it
in
• Sunscreen
• Bug Spray
• Hat (recommended)
• Rain gear (watch the weather forecast, and be prepared)
• Backpack, so boys can carry their own
belongings
• Pencil or Pen
• Spending money for the Trading Post
• A Positive Attitude
Please Leave at Home
• Pets
• Pocket Knives
• Electronic devices (ipods, MP3 players, youth cell phones, hand held
games, etc)
• Matches, lighters or fireworks
• Unregistered youth, young children or
siblings not working at camp
In addition, each group may find it helpful to pile backpacks, water bottles, etc. in a
wagon to take from station to station. This is optional.
The Buddy System
Please enforce the Buddy System at camp! No boy is allowed to
go anywhere without another Scout or Buddy, this includes the
restroom and the Trading Post. Please discuss the Buddy System
with your scouts and all leaders before coming to camp. This will
help keep your group together and safe.
Lunch and Drinking Water
Everyone will need to bring their own lunch and cold storage. We suggest sack
lunches that can be kept in a cooler until lunchtime. You will have plenty of time for
lunch, so please leave coolers in your car. Feel free to bring camp chairs and shade
pop-ups to create your own shade area. Some (not all) camps have covered areas,
which you are also welcome to use. Everyone should bring a refillable water bottle,
labeled with your name and Pack number. Refill stations will be available throughout each camp.
Your Pack can choose where you eat lunch, but each Pack should stay together.
Please supervise your scouts. They may visit the trading post, restrooms, etc. using
the buddy system.
Practice ‘Leave No Trace’ and take your trash to the dumpster or your car. Not all
camps have trash facilities, so please ‘haul it in, haul it out.’ THANK YOU!!
8
Early Departure
The Camp Director must sign out EVERYONE who needs to leave EARLY. Early
is considered any time before closing ceremonies. The adult picking up a scout must
be listed in the early release section of the Health and Medical form, or the boy cannot be released. Volunteers need to sign out with the Camp Director, so we know
who is still there, and if replacements are needed.
Trading Post
Each camp will have a Trading Post where snack foods, candy, cold drinks, snow
cones, camp t-shirts and Scout Souvenirs can be purchased. What do the scouts
LEARN at The Trading Post??? They learn decision-making skills, responsibility,
honesty, budgeting, math, integrity, delayed gratification, time-management, and so
much more! The Trading Post is an important and exciting part of camp for the
scouts! We recommend that every scout have money to spend at the Trading Post.
Proceeds from the Trading Post help keep the costs of camp down. Recommended
spending money is $15.
Phones and other Electronic Distractions
The Camp Director will have a phone available for emergencies only. All adults are
expected to leave their personal cell phones off and refrain from use while at camp.
Scouts bringing cell phones will be asked to leave them with their Walking Leaders
while at camp. Please leave all other electronic devices at home.
Restrooms & Port-a-Potties when Nature Calls
All locations have port-a-potties available for your use. All scouts must use the Buddy
System when visiting these facilities. The facilities are in plain view of camp and can
be accessed any time.
Praise and Discipline
When you see a boy do something good, praise him openly in front of the group.
When you see a boy behaving inappropriately, pull him aside and talk to him about
his behavior. Make sure you are out of earshot, but within sight of others. Please
do not belittle or embarrass him. If he continues to misbehave, contact the Camp Director. Remember to maintain 2-deep leadership at all times.
Water + Dirt = Mud
If there is any source of water, the scouts will most likely find it and get wet. Water
and dirt make mud. The scouts will be doing a variety of activities that could include
sweating, getting dirty and coming home stinky. They will also have a wonderful
time! So, have the shower ready :)
9
Medicine and First Aid
ALL medications at camp need to be in the original containers, labeled with name
and pack number, to turn over to the Health Officer at check-in. Rescue inhalers and
Epi-pens may remain with walking leaders, but must be reported to the Health Officer.
Report ALL injuries to the Camp Health Officer, no matter how small they may be.
The Health Officer can be found at the First Aid Station in the Trading Post area.
NEVER send a boy to the First Aid Station alone. Use the Buddy System at all times
at camp.
Emergency Procedures
Listen for 3 blasts on the horn. It is the signal for emergency. Gather at the
gathering area and specific instructions will be given.
Severe Weather
Electrical Storm: Stay away from trees and buildings, take scouts quickly to your
cars.
Severe Rain or Hail: Take cover in nearest shelter or take scouts to your cars and
wait for directions from Camp Director.
Winds: Stay away from trees and get into an open area.
If your camp cannot take place because of severe weather, camp staff will do their
best to contact you with a change of date or location. This is one reason it is important to have accurate and legible information on your Pack Registration form.
Lost Boy
Send an adult to contact Camp Director
Search in the most likely places: restrooms, vehicles, trading post, etc.
Follow the directions of the Camp Director
Health Emergencies
Stop life-threatening dangers to keep victim from further harm
Notify Camp Health Officer and Camp Director immediately
Contact parents/guardians
Child Abuse
Separate victim from abuser
Notify Camp Director immediately
LINKS to make your life easier:
Youth Protection Training: http://www.scouting.org/Training/youthprotection.aspx
Health and Medical Record form: http://www.scouting.org/filestore/HealthSafety/pdf/680-001_ABC.pdf
Tour and Activity Plan Online: http://www.scouting.org/scoutsource/healthandsafety/tourplanfaq.aspx
Tour and Activity Plan Paper Form: http://www.scouting.org/filestore/pdf/680-014.pdf
10
2015 Day Camp Schedule
Camp
Program
Dates
Days
Checkin Time
End
Time
Camp Director
#1
Cub &
Web
May
29
Fri
Optimist Park, Elmcrest & 5th
North, Mountain Home
8:30
3:30
Karen Crossley 447-9681
[email protected]
May 7st
7-8pm
1150 N. 8th E, Mt Home
#2
Cub &
Web
May
30
Sat
Nampa South LDS Stake Center
7809 Deer Flat Rd. Nampa
8:30
3:30
Jayne Heaps 466-4618
[email protected]
May 14th 6-7pm
1500 Smith Ave, Nampa
*#3*
Web
Only
June
2-3
TuesWed
Curtis Park, entrance at
14230 Channel Rd, Caldwell
8:30
3:30
Michele Trowell 467-4032
[email protected]
May 14th 6-7pm
1500 Smith Ave, Nampa
#4
Cub &
Web
June
4
Thurs
LDS Stake Center Grounds
3700 S.Maple Grove Rd, Boise
8:30
3:30
Stephanie 828-399-1270
[email protected]
May 14th 6-7pm
3800 Grand Forest, Boise
#5
Cub &
Web
June
5
Fri
LDS Stake Center Grounds
3700 S.Maple Grove Rd, Boise
8:30
3:30
Stephanie 828-399-1270
[email protected]
May 14th 6-7pm
3800 Grand Forest, Boise
#6
Cub &
Web
June
6
Sat
LDS Stake Center Grounds
3700 S.Maple Grove Rd, Boise
8:30
3:30
Stephanie 828-399-1270
[email protected]
May 14th 6-7pm
3800 Grand Forest, Boise
#7
Cub &
Web
June
8
Mon
LDS Stake Center Grounds
3700 S.Maple Grove Rd, Boise
8:30
3:30
Stephanie 828-399-1270
[email protected]
May 14th 6-7pm
3800 Grand Forest, Boise
#8
Cub &
Web
June
9
Tues
LDS Stake Center Grounds
3700 S.Maple Grove Rd, Boise
8:30
3:30
Stephanie 828-399-1270
[email protected]
May 14th 6-7pm
3800 Grand Forest, Boise
#9
Cub &
Web
June
10
Wed
LDS Stake Center Grounds
3700 S.Maple Grove Rd, Boise
8:30
3:30
Stephanie 828-399-1270
[email protected]
May 14th 6-7pm
3800 Grand Forest, Boise
*#10
Web
Only
June
11-12
ThursFri
Curtis Park, entrance at
14230 Channel Rd, Caldwell
8:30
3:30
Michele Trowell 467-4032
[email protected]
May 14th 6-7pm
1500 Smith Ave, Nampa
#11
Cub &
Web
June
12
Fri
Montgomery Farm
668 Sugar Ave, Ontario
8:30
3:30
Jan Partin 899-7304
[email protected]
May 13th 7:00pm
Montgomery Farm
#12
Cub &
Web
June
13
Sat
LDS Stake Center Grounds
980 W. Central Rd, Emmett
8:30
3:30
Sherri Dowdle 841-7105
[email protected]
May 7st
6-7pm
190 S.Locust Grove
#13
Cub &
Web
June
13
Sat
Montgomery Farm
668 Sugar Ave, Ontario
8:30
3:30
Jan Partin 899-7304
[email protected]
May 13th 7:00pm
Montgomery Farm
#14
Cub &
Web
June
16
Tues
Curtis Park, entrance at
14230 Channel Rd, Caldwell
8:30
3:30
Debbie Hyer 412-0130
[email protected]
May 14th 6-7pm
1500 Smith Ave, Nampa
#15
Cub &
Web
June
17
Wed
Curtis Park, entrance at
14230 Channel Rd, Caldwell
8:30
3:30
Debbie Hyer 412-0130
[email protected]
May 14th 6-7pm
1500 Smith Ave, Nampa
#16
Cub &
Web
June
18
Thurs
Curtis Park, entrance at
14230 Channel Rd, Caldwell
8:30
3:30
Sherri Dowdle 841-7105
[email protected]
May 7st
6-7pm
190 S.Locust Grove
#17
Cub &
Web
June
19
Fri
LDS Stake Center Grounds
3700 S.Maple Grove Rd, Boise
8:30
3:30
Sherri Dowdle 841-7105
[email protected]
May 7st
6-7pm
190 S.Locust Grove
#18
Cub &
Web
June
20
Sat
Nampa South LDS Stake Center
7809 Deer Flat Rd. Nampa
8:30
3:30
Debbie Hyer 412-0130
[email protected]
May 14th 6-7pm
1500 Smith Ave, Nampa
#19
Cub &
Web
June
Sat
Zim’s Hot Springs
2995 Zims Road, New Meadows
8:30
3:30
Jan Partin 899-7304
[email protected]
May 7th 7:00pm
400 Elo Road, McCall
#20
Cub &
Web
June
23
Tues
LDS Stake Center Grounds
3700 S.Maple Grove Rd, Boise
8:30
3:30
Sherri Dowdle 841-7105
[email protected]
May 7st
6-7pm
190 S.Locust Grove
#21
Cub &
Web
June
24
Wed
LDS Stake Center Grounds
3700 S.Maple Grove Rd, Boise
8:30
3:30
Sherri Dowdle 841-7105
[email protected]
May 7st
6-7pm
190 S.Locust Grove
#22
Cub &
Web
June
25
Thurs
Nampa South LDS Stake Center
7809 Deer Flat Rd. Nampa
8:30
3:30
Jayne Heaps 466-4618
[email protected]
May 14th 6-7pm
1500 Smith Ave, Nampa
*#23
Web
Only
June
26-27
Fri-Sat
LDS Stake Center Grounds
3700 S.Maple Grove Rd, Boise
8:30
3:30
Michele Trowell 467-4032
[email protected]
May 14th 6-7pm
1500 Smith Ave, Nampa
#24
Cub &
Web
June
30
Tues
Curtis Park, entrance at
14230 Channel Rd, Caldwell
8:30
3:30
Sherri Dowdle 841-7105
[email protected]
May 7st
6-7pm
190 S.Locust Grove, Boise
20
Location
Orientation & T-shirt Pick-up
Steps to Success
Preparing for Day Camp
January
• Attend Pow Wow class for details about camp
• Distribute and collect Health and Medical Record forms. Make a copy for day camp, keep original. You can do this step in September :) for next year!
• Decide a date for camp
• Decide which adult leaders or parents will attend camp
2 adults for first 10 scouts, 1 more adult for 11-15, 1 more adult for 16-20, etc.
Gather names and Health and Medical Record forms for all adults
• Collect payments and sizes for adults purchasing a t-shirt
• Gather names, Health and Medical Record forms, t-shirt sizes, and payment for all scouts
February
Register for camp early! • Bring registration form listing all scouts and leaders, all Health and Medical Record forms for
youth and adults and full payment to BSA Ore-Ida Council Office Ore-Ida Council Boy Scouts of America, 8901 W. Franklin Road, Boise, Idaho 83709
April • Confirm which adult leaders or parents are attending camp. Gather Health and Medical
Record forms for all adults.
• File Tour and Activity Plan May
• Attend Day Camp Orientation, and pick up t-shirts, go to the correct orientation for your
camp. Check the 2015 Day Camp Schedule for details.
• Contact your Camp Director with any changes in scouts or leaders attending camp
Check the weather, Bring a Lunch, Be Prepared, and Get Excited!!!
**Camp registration will be capped at 135 scouts maximum!**
Pack registration does not guarantee a placeholder for late
registrants, even from the same pack.
<<Double Check>>
Have you:
-Provided and e-mail and phone number for your pack contact person? (YOU!)
-Registered all the scouts in your pack?
-Recruited enough adult leaders to supervise at camp?
-Is at least one leader a BSA registered adult with Youth Protection Training?
-Collected all Health and Medical Record Forms for scouts and adults?
-Submitted your Tour and Activity Plan?
-Added Camp Orientation to your calendar?
12
Camp Number
Pack Number
Fill out form completely
Please PRINT Clearly
First Contact Person_________________________________ position __________________________
Email _____________________________________________ cell phone_________________________
Second Contact_____________________________________ position___________________________
Email_____________________________________________ cell phone_________________________
Two Adult Walking Leaders for up to 10 scouts.
Add One Leader for every 5 additional scouts.
*BSA registered adults must be Youth Protection Trained (YPT)*
Medical
Name (first and last)
Aware
Please PRINT clearly
BSA
Registered
Adult 1
Adult 2
YPT Date _____
Shirt size
Only if
purchasing
Only if
purchasing
Scout 1
Scout 2
Scout 3
Scout 4
T-Shirt Sizes
Youth Medium
Youth Large
Adult Small
Adult Medium
Adult Large
Adult XL
Adult 2XL and up - $12.00
Until April 8, 2014
One-Day Camp - $30
Two-Day Camp - $45
$_____ x ____# of boys = $_______
After April 8, 2014
One-Day Camp - $35
Two-Day Camp - $50
$_____ x ____# of boys = $_______
Scout 5
Gold Card Discount
$5.00 x _____# of boys = ($______)
Scout 6
Additional Camp T-Shirts
Scout 7
$10.00 x ____# of shirts = $_______
$12.00 x ____# of shirts = $_______
Scout 8
Scout 9
Scout 10
**All Fees and Health Forms must be turned in at registration**
Total Fees Paid $________________
____________
Date
______________
Transaction #
Medical
Name (first and last)
Shirt Size
Aware
Adult 3
Only if
purchasing
Scout 11
Scout 12
Scout 13
Scout 14
Scout 15
Adult 4
Only if
purchasing
Scout 16
Scout 17
Scout 18
For Office Use Only
Scout 19
Scout 20
Adult 5
Only if
purchasing
Scout 21
Scout 22
Scout 23
Scout 24
Scout 25
Adult 6
Scout 26
Scout 27
Scout 28
Scout 29
Scout 30
Only if
purchasing
T-Shirt Size:
A
YM
Part A: Informed Consent, Release Agreement, and Authorization
High-adventure base participants:
Full name: _________________________________________ Expedition/crew No.:________________________________
DOB:
_________________________________________
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/
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, 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.
(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.
or staff position:____________________________________
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/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 further
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 BSA, and I
specifically waive any right to any compensation I may have for any of the foregoing.
!
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.
List participant restrictions, if any:
!
None
________________________________________________________
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, Florida 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 specifically 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)
Second parent/guardian signature for youth:_______________________________________________________________________ Date:_______________________________
(If required; for example, California)
Complete this section for youth participants only:
Adults Authorized to Take to and From Events:
You must designate at least one adult. Please include a telephone number.
Name: _______________________________________________________
Name: _______________________________________________________
Telephone: ___________________________________________________
Telephone: ___________________________________________________
Adults NOT Authorized to Take Youth To and From Events:
Name: _______________________________________________________
Name: _______________________________________________________
Telephone: ___________________________________________________
Telephone: ___________________________________________________
680-001
2014 Printing
B
Part B: General Information/Health History
High-adventure base participants:
Full name: _________________________________________ Expedition/crew No.:________________________________
DOB:
_________________________________________
or staff position:____________________________________
Age:____________________________ Gender:_________________________ Height (inches):___________________________ Weight (lbs.):_____________________________
Address:_________________________________________________________________________________________________________________________________________
City:___________________________________________ State:___________________________ ZIP code:_______________ Telephone:_______________________________
Unit leader:_________________________________________________________________________________ Mobile phone:__________________________________________
Council Name/No.:___________________________________________________________________________________________________ Unit No.:_____________________
Health/Accident Insurance Company:__________________________________________________ Policy No.:____________________________________________________
!
Please attach a photocopy of both sides of the insurance card. If you do not have medical insurance,
enter “none” above.
!
In case of emergency, notify the person below:
Name:____________________________________________________________________________ Relationship:____________________________________________________
Address: _____________________________________________________________ Home phone:________________________ Other phone:__________________________
Alternate contact name:_____________________________________________________________ Alternate’s phone:_______________________________________________
Health
History
Do you currently have or have you ever been treated for any of the following?
Yes
No
Condition
Diabetes
Explain
Last HbA1c percentage and date:
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 heartrelated death of a family member before age 50.
Stroke/TIA
Asthma
Last attack date:
Lung/respiratory disease
COPD
Ear/eyes/nose/sinus problems
Muscular/skeletal condition/muscle or bone issues
Head injury/concussion
Altitude sickness
Psychiatric/psychological or emotional difficulties
Behavioral/neurological disorders
Blood disorders/sickle cell disease
Fainting spells and dizziness
Kidney disease
Seizures
Last seizure date:
Abdominal/stomach/digestive problems
Thyroid disease
Excessive fatigue
Obstructive sleep apnea/sleep disorders
CPAP: Yes £
List all surgeries and hospitalizations
Last surgery date:
No £
List any other medical conditions not covered above
680-001
2014 Printing
B
Part B: General Information/Health History
High-adventure base participants:
Full name: _________________________________________ Expedition/crew No.:________________________________
DOB:
_________________________________________
or staff position:____________________________________
Allergies/Medications
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
Medication
Plants
Food
Insect bites/stings
Explain
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
INDICATE ON A SEPARATE SHEET AND ATTACH.
Medication
YES
NO
Dose
Frequency
Reason
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)
Bring enough medications in sufficient 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.
!
!
Immunization
The following immunizations are recommended by the BSA. 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
Tetanus
Pertussis
Diphtheria
Measles/mumps/rubella
Polio
Chicken Pox
Hepatitis A
Date(s)
Please list any additional information
about your medical history:
_____________________________________________
_____________________________________________
_____________________________________________
_____________________________________________
DO NOT WRITE IN THIS BOX
Review for camp or special activity.
Reviewed by:_____________________________________________
Hepatitis B
Date:____________________________________________________
Meningitis
Further approval required:
Influenza
Reason:_________________________________________________
Other (i.e., HIB)
Approved by:_____________________________________________
Exemption to immunizations (form required)
Date:____________________________________________________
Yes
No
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2014 Printing