Quail Hill Scout Reservation
2015 Parents and Leaders Guide
A Nationally Accredited Camp
Day Camp
Half Week Resident Camp
Webelos Full Week Resident Camp
Monmouth Council BSA
705 Ginesi Drive
Morganville, NJ 07751
(732) 536-2347
www.monmouthbsa.org
www.qhsrcamp.org
Program Information
2015 DAY CAMP PROGRAM
Our Day Camp program is set up to offer a wide variety of activities based on seven separate
program areas which include Pool, Crafts, Nature, Scout Skills, Pond, Games and BB & Archery.
Scouts are broken up into Dens based on their age. These Dens attend each area on a varying daily
rotation. All activities are planned to ensure that they are age appropriate. Our main focus during
Day Camp is FUN. Cub advancement opportunities will also be offered.
Week 1 – July 6 – 10, 2015  Week 2 – July 13 – 17, 2015  Week 3 – July 20 – 24, 2015
Week 4 – July 27 – July 31, 2015  Week 5 – August 3 – 7, 2015  Week 6 – August 10 – 14, 2015
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Available to all Cub Scouts, Webelos and Boy Scouts
Attend as many weeks as desired
Arrive Monday – Friday at 8:45 am
Depart Monday – Friday at 4:30 pm
Bring a bagged lunch – paper bags only – NO lunchboxes – (Name on Bag)
Transportation available
Friday evening at 5:30 pm is Family BBQ and campfire ($8.00 each)
Must submit BSA Annual Health and Medical Record (Parts A and B) at least two weeks prior to camp.
Participants are encouraged to behave based on the values of the Scouting program.
2015 RESIDENT CAMP PROGRAMS
Our Resident Camp programs utilize our basic Day Camp program during the day and provide
additional advancement opportunities, outdoor activities as well as camping experiences in the
evenings. Webelos Resident Camp (session 2) is a week-long program specifically for boys entering
their first or second year of Webelos. Our Half Week Resident Camps (session 1 & 3) are for all
Cubs and Webelos that might not be ready for a full week away from home.
Session 1 – July 21 – 24, 2015  Session 2 – July 26 – July 31, 2015  Session 3 – August 4 – 7, 2015
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Half Week Resident Camp is available to all Cubs and Webelos ONLY
Full Week Resident Camp is available to Webelos ONLY.
Check-in is 5:30pm on the beginning day of the session.
Resident Camps end Friday at 4:30 pm
Campers should eat dinner prior to checking in for Resident Camps.
All Meals are provided during Resident Camps
Half Week Resident camp can be combined with Day Camp for that week for a cost of $320.00
Friday evening at 5:30 pm is Family BBQ and campfire ($8.00 each)
Campers will be sleeping two to a tent in canvas wall tents on spring steel cots
Must submit BSA Annual Health and Medical Record (Parts A, B and C) at least two weeks prior to camp.
Participants are encouraged to behave based on the values of the Scouting program.
VOLUNTEER LEADERS – Volunteer leaders are a very important part of our Summer Camp program.
Being a volunteer leader gives you the opportunity to help supply a top notch program to a large number of
Scouts. It also allows you to spend some real quality time with your son and to be a real part of his Scouting
experience. You can volunteer for one day, one week or the entire summer. Any help is greatly appreciated.
Volunteers must fill out the Volunteer application contained in this guide and submit it to Monmouth
Council. Discount rebates are available to leaders that volunteer for the entire week or session. These
rebates are limited and are on a first come-first served basis.
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Volunteer for an entire week of Day Camp and receive a $50.00 rebate.
Volunteer for an entire session of Half Week Resident Camp and receive a $50.00 rebate.
Volunteer for the entire session of Full Week Resident Camp and receive a $100.00 rebate.
Volunteers must currently be registered as an adult leader in the BSA.
Volunteers must be currently trained in Youth Protection and Hazardous Weather Training.
(Training is available online at www.monmouthbsa.org)
Volunteers of a full week or session must attend a day of volunteer training.
Volunteers must complete and submit a BSA Annual Health and Medical Record.
(form is located in the forms section of this leaders guide.)
Volunteers must complete and submit a Summer Camp Volunteer Application.
(form is located in the forms section of this leaders guide.)
Volunteers will receive a Staff T-shirt as well as a Camp Patch.
PASSWORDS – The safety of the participants as well as the safety of our Staff are of paramount importance.
With this in mind, a password is required to be filled in on the camper application. This password is
extremely important. It allows you or someone that you send to pick up your Scout at the end of the day. It
also allows us to ask questions or permission for something over the phone and know we are talking to the
person responsible for making such decisions. Please take the time to choose a password that you will
remember and fill it in on the application. Also please ensure that all contact information is printed legibly on
the camper application in case we need to contact you. This camper application is located in the forms
section of this leaders guide.
BSA ANNUAL HEALTH AND MEDICAL RECORD – As of 2010 it is required for all Scouts and
leaders to fill out a BSA Annual Health and Medical Record form each year. This form is included in the
forms section of this leaders guide. Scouts or leaders attending Day Camp need to fill out section A and B.
Scouts and leaders attending Resident Camp must fill out section A, B and C. Sections A and B must be
signed by the parent. For Resident Camp attendees, Section C must be signed by the doctor. Be sure to
include immunization information and prescription drug information. The Annual Health and Medical
Record is located in the forms section of this leaders guide. Please submit at least two weeks before arrival at
camp.
FINANCIAL ASSISTANCE - Camperships are available to all Scouts based on financial need. Please
make sure applicants need the help or you may take it away from someone who really does. All campership
applications are due at Monmouth Council no later than Friday, May 4, 2015. Any applications received
after this date, will not be considered. Campership amounts are not fixed, but flexible according to need.
Camperships do not cover the full camp fee and can only be submitted for a single session. Applications
must be signed by the unit leader and the parent. The campership application is located in the forms section
of this leaders guide.
ADVANCEMENT - Achievements offered during camp change day to day and week to week depending on
the scheduled program, weather conditions, staff availability and time factors. At Quail Hill, our focus is on
FUN first and achievements second. A list of completed achievements will be sent via email after summer
camp. Please ensure your email address on the camper application is completely legible.
Awards are purchased by the pack after camp. Check with your pack to see if they cover the cost of these
awards. If not, the parent may be required to cover the cost.
Financial Information
2015 DAY CAMP PROGRAM
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$245.00 per week if paid in full by May 1, 2015.
$260.00 per week if Paid after May 1, 2015 but before June 12, 2015.
$270.00 per week if paid after June 12, 2015.
2015 HALF WEEK RESIDENT CAMP PROGRAM
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$200.00 per week if paid in full by May 1, 2015.
$215.00 per week if Paid after May 1, 2015 but before June 12, 2015.
$225.00 per week if paid after June 12, 2015.
2015 HALF WEEK RESIDENT / DAY CAMP COMBO PROGRAM
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$305.00 per week if paid in full by May 1, 2015.
$320.00 per week if Paid after May 1, 2015 but before June 12, 2015.
$330.00 per week if paid after June 12, 2015.
2015 WEBELOS FULL WEEK RESIDENT CAMP PROGRAM
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$305.00 per week if paid in full by May 1, 2015.
$320.00 per week if Paid after May 1, 2015 but before June 12, 2015.
$330.00 per week if paid after June 12, 2015.
MULTI-WEEK DISCOUNT – A $10.00 discount is available for each additional Day Camp
session attended. One week must be at full price as listed above. Not available for resident camp
programs.
6 WEEK DAY CAMP DISCOUNT – Sign up for ALL six weeks of Cub Scout Day Camp and
receive 1 week FREE. That’s ALL 6 weeks for $1300. When receiving this discount, NO other
discounts apply.
BUSING – Bus transportation to Day Camp is available for an additional cost of $65.00 per week per Scout.
There will be a required minimum of 10 passengers to run the bus each week. We offer the following bus
stops: Busing to Middlesex District will be available. Stops are to be determined.
Costco at the Sea View Square Mall  Sea Girt Elementary School
Wall High School  Farmingdale Methodist Church  St. Veronica’s Church - Howell
Red Bank Middle School  Meadowbrook School – Eatontown  Middletown Village School Middle
Road School – Hazlet  Frank Defino Central School - Marlboro
FAMILY FUN NIGHT – Every Friday starting at 4:30pm is Family Fun Night. This is your opportunity to
come out and see what your Scout has been doing all week. Come enjoy our barbeque, games and campfire
show. Scouts returning a permission slip will be allowed to stay at camp until their parents come to join them
(between 4:30 and 6:00pm). Cost is $8.00 per person. Camp participants and volunteers are free.
CAMP CARE – For those of you that need to drop your child off early or pick them up late, we offer precamp and post camp care. Pre-camp care begins at 7:30AM and Post-camp care ends at 6:00PM. This
program costs an additional $75.00 per child. The cost is the same whether you use all or only part of the
program.
TRADING POST – Our Trading Post is open all day and has a wide variety of snacks and drinks as well as
many other camp and Scout supplies. Fair prices and friendly service.
REFUND POLICY – All program sessions include a $50.00 non-refundable deposit. Refunds for the
remaining fees will only be made for serious illness, injury or death in the immediate family or if Scout is
required to attend summer school which conflicts with the camp schedule. All refund requests must be made
in writing with proof and submitted to the Monmouth Council Service Center prior to August 31, 2015.
SUGGESTED RESIDENT CAMP EQUIPMENT LIST
Clothing
Sleeping
____ 1 complete change of everything
for each day
____ Extra socks (many pairs)
____ Cub uniform shirt w/scarf
____ Bathing suit/towel
____ Waterproof shoes (boots)
____ Extra towel
____ Rain Gear (a must!)
____ Sleeping bag
____ Ground cloth or plastic sheet
____ Pillow
____ Foam pad or blanket to cover cot
____ Dry, clean socks (many pairs)
_____ ___________________________
_____ ___________________________
_____ ___________________________
Gear
____ Clothing suitable to weather (in layers)
____ Sweat shirt
____ Extra plastic bag for soiled clothing
____ Sneakers or Boots (no sandals/flip-flops)
____ _____________________________
*Optional Items
____ Watch
____ Camera
____ Notebook & pencil
____ Mosquito repellent (non-aerosol)
Other Needs
What Not To Bring to Camp
____ Canteen, plastic cup, or water bottle
____ Grooming kit, soap in a case, comb,
____ Sunscreen (non aerosol)
personal items
____ Flashlight and batteries
____ Wallet with ID and money
for trading post
____ Hat
____ Day Pack-Backpack
► Cell phones
► Electronic games, TV etc.
► Knives
► Fishing gear
► Walkie talkies
► The latest “craze” toys
► NO flip-flops
► Jewelry
Pack all things that you wish to keep dry, in separate plastic bags. Pack things on top that you
will need first.
MARK ALL EQUIPMENT
Parents are encouraged to put the campers name and address on all clothing and equipment. Each
year there are many items of clothing and equipment lost, unidentified, and unclaimed. All
unclaimed items will be returned to the Council Office at the end of the camping season and kept
until September 30th.
SUGGESTED DAY CAMP EQUIPMENT LIST
Other Needs
What Not To Bring to Camp
____ Canteen, plastic cup, or water bottle
► Cell phones
____ Bathing suit/towel
► Electronic games, TV etc.
____ Day Pack-Backpack
► Knives
____ Hat
► Fishing gear
____ Sunscreen / Bug spray
► Walkie talkies
____ Wallet with ID and money
► The latest “craze” toys
for trading post
► NO flip-flops
____ Rain Gear (a must!)
____ Bagged Lunch – paper bags only – NO Lunch boxes (Name on Bag)
____ Sneakers or Boots (no flip-flops)
Quail Hill Scout Reservation
Summer Camp Volunteer Application
Volunteers are the backbone of the Scouting program. Volunteerism is no less important to
ensure a superior quality summer program. With this in mind we would like to ask you to
consider volunteering your time to help deliver the best possible summer program to our Cub
Scouts and Webelos. You can volunteer for one day, one week or the entire summer. Any help
is greatly appreciated.
Print an “X” in the day(s) of the week(s) of camp you would like to volunteer for:
Week
July 06th - 10th
July 13th - 17th
July 20th - 24th
July 27th - 31st
Aug 03rd - 07th
Aug 10th - 14th
Full Wk
M T W Th
F Overnight
Please return this application by
dropping it off, U.S. mail or fax to:
(732) 536-2850
Monmouth Council BSA
Attn: QHSR Volunteer App.
705 Ginesi Drive
Morganville, NJ. 07751
Questions?
Call 732-536-2347
Volunteer for an entire week of Day Camp and receive a $50.00 rebate.
Volunteer for an entire session of Half Week Resident Camp and receive a $50.00 rebate.
Volunteer for the entire session of Full Week Resident Camp and receive a $100.00 rebate.
These rebates are limited and are on a first come-first served basis.
Those who volunteer for an entire week will be given a Staff Shirt and Camp Patch. Rebate
checks will be mailed out shortly after the Summer Camp season.
* Volunteers must be currently registered as an adult leader with the BSA.
* Volunteers must be currently trained in Youth Protection, Hazardous Weather Training,
Safe Swim Defense and Safety Afloat.
* Training courses are available online at www.myscouting.org .
* Full week volunteers must attend a day of volunteer training.
* Volunteers must complete a BSA Annual Health and Medical Record.
* Volunteer agreement letters along with dates of training, will be mailed out as confirmation of
your service.
_________________________ ________________________ ________________________________
First Name
Last Name
Email Address
____________________________________________________________ ______________________
Address/City/State/Zip
Adult Shirt Size
_________________________
Home Phone Number
________________________
Work Phone Number
_________________________
Cell Phone Number
____________________________________________________________________________________
Please list your current Boy Scouts of America membership and your leadership positions held with BSA
_____________________________________________________________________________
Please list any special job skills, hobbies or talents that may benefit the Cub Scout Program at Quail Hill.
(ie. I can play the kazoo, accordion, guitar, nose flute etc. Keep in mind our “Sea Adventure” program theme.)
_______________________________________
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_______________
Signature
Date
Pack #
Monmouth Council 2015 Campership Application
Please Print
Name: ________________________________
Address: ______________________________
ZIP Code: ____________________
(circle one)Troop/Crew/Post#_________
Date of Birth: _____________________
City: ____________________________
Telephone: ________________________
Rank: _____________________________
Campership Request (Check One):
( ) Boy Scout Basic Program
( ) Boy Scout Outback Program
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Cub Scout Basic Day Camp
Cub Scout ½ Week Resident Camp
Cub Scout Full Week Resident Camp
Boy Scout Day Camp
Financial Need:
No. of children in household: ___________
Children in college: ________
Mother’s Occupation __________________
Father’s Occupation ________________
Total Annual Household Income _________
Explain reason for assistance (please be specific): _____________________________________
______________________________________________________________________________
______________________________________________________________________________
Campership Request: (Use full price of program without discounts when calculating)
Share of camp cost from family:
$_________
Share of camp cost from unit, fundraisers, etc:
$_________
Amount requested for campership:
$_________
Note: Camperships are not approved for the entire camp fee.
I understand that this is a request for financial assistance for my son to attend camp and that
camperships will be awarded on the basis of genuine need and availability of funds. All
information will be kept confidential. Camperships are only accepted for one week of
program per Scout.
Parent Signature: ____________________________________
Date: _________________
Unit Leader's Approval: _______________________________
Date: _________________
(Note: Unit Leaders MUST screen campership requests before submitting them.)
Please forward application to:
Monmouth Council Campership Fund
705 Ginesi Drive
Morganville, NJ 07751
Campership applications must be received by May 4, 2015 to be considered.
................................................................ Office Use Only................................................................
Date Received: _________________________
Amount Approved: _________________
Approved by: _________________________________
Date: _________________
Campership # ______________
Quail Hill Scout Reservation 2015 Summer Camp Application
“MEDIEVAL TIMES”
Boy Scouts of America
Monmouth Council
Name _________________________________________ Pack _______ Council ____________________________
Address __________________________________ City _______________________ St _______ Zip ____________
Birth Date _____ / _____ / _____
Entering Grade __________
Scout’s Rank at Camp _________________
Parent/Guardian Name ____________________________________ Email _________________________________
Home Phone _____________________ Work Phone _____________________ Cell Phone ____________________
T-Shirt Size (Circle) Adult Sm Adult Med Adult Lg Adult XL (If no size is indicated Adult Sm will be given)
NOTE: A password is needed to pick up your child.
Please indicate password to be used: __________________
BUS STOP SELECTION: _____________________________ALT SELECTION: ________________________________
Bus Stop confirmations and schedule will be sent to all bus riders one week prior to scouts arrival at camp
Cub Scout Day and Resident Camps (Check all that apply. Write in # attending Barbecue.)
Day Camp Day Camp
Week 1
Week 2
July 6-10 July 13-17
Day Camp - $260 (ALL for $1300)
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Day Camp
Week 3
July 20-24
Day Camp
Week 4
July 27-31
Day Camp
Week 5
Aug 3-7
Day Camp
Week 6
Aug 10-14
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Resident
Session #1
July 21-24
Resident
Session #2
July 26-31
Resident
Session #3
Aug 4-7
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Full Week Resident Camp - $320
(Webelos only)
N/A
N/A
N/A
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N/A
N/A
Half Week Resident Camp - $215
N/A
N/A
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N/A
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N/A
Day/Resident Camp Combo - $320
N/A
N/A
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N/A
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N/A
Early Bird Discount—$15 Off
(pay in Full by May 1, 2015)
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Multi-Week Discount - $10 Off
N/A
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Bus - $65 (Day Camp Only)
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Camp Care - $75
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BBQ - $8 per person
Late Fee - $10 (paid after June 12)
Total Fees
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#___ 
#___
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#___
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$_______
$_______
$_______
$_______
$_______
$_______
Den Friend(s) [Must be in same grade] 1st Choice ____________________
2nd Choice ____________________
Resident Camp Tent Partner: 1st Choice ___________________
2nd Choice ____________________
Charge to:
Visa MasterCard Discover American Express
Amount Enclosed $ _____________
Account # ________________________________Sec Code ________ Exp. __________ Signature _______________________
or make checks or money orders payable to Monmouth Council, BSA • Mail to: 705 Ginesi Drive, Morganville, NJ 07751
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
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
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
680-001
2014 Printing
Part C: Pre-Participation Physical
This part must be completed by certified and licensed physicians (MD, DO), nurse practitioners, or physician assistants.
High-adventure base participants:
Full name: _________________________________________ Expedition/crew No.:________________________________
DOB:
_________________________________________
or staff position:____________________________________
You are being asked to certify that this individual has no contraindication for participation inside a
Scouting experience. For individuals who will be attending a high-adventure program, including one
of the national high-adventure bases, please refer to the supplemental information on the following
pages or the form provided by your patient.
!
!
Examiner: Please fill in the following information:
Yes
No
Explain
Medical restrictions to participate
Yes
No
Allergies or Reactions
Explain
Yes
No
Allergies or Reactions
Medication
Plants
Food
Insect bites/stings
Explain
Height (inches):__________________ Weight (lbs.):__________________ BMI:__________________ Blood Pressure:__________________/__________________ Pulse:__________________
Normal
Abnormal
Explain Abnormalities
Examiner’s Certification
I certify that I have reviewed the health history and examined this person and find
no contraindications for participation in a Scouting experience. This participant
(with noted restrictions):
Eyes
True
Ears/nose/
throat
False
Explain
Meets height/weight requirements.
Does not have uncontrolled heart disease, asthma, or hypertension.
Lungs
Has not had an orthopedic injury, musculoskeletal problems, or
orthopedic surgery in the last six months or possesses a letter of
clearance from his or her orthopedic surgeon or treating physician.
Heart
Has no uncontrolled psychiatric disorders.
Has had no seizures in the last year.
Abdomen
Does not have poorly controlled diabetes.
If less than 18 years of age and planning to scuba dive, does not have
diabetes, asthma, or seizures.
Genitalia/hernia
For high-adventure participants, I have reviewed with them the
important supplemental risk advisory provided.
Musculoskeletal
Examiner’s Signature:____________________________________ Date: ________________
Provider printed name:_________________________________________________________
Neurological
Address:_______________________________________________________________________
City:______________________________________ State:_____________ ZIP code:__________
Other
Office phone:__________________________________________________
Height/Weight Restrictions
If you exceed the maximum weight for height as explained in the following chart and your planned high-adventure activity will take you more than 30 minutes away from an
emergency vehicle/accessible roadway, you may not be allowed to participate.
Maximum weight for height:
Height (inches)
Max. Weight
Height (inches)
Max. Weight
Height (inches)
Max. Weight
Height (inches)
60
166
65
195
70
226
75
Max. Weight
260
61
172
66
201
71
233
76
267
62
178
67
207
72
239
77
274
63
183
68
214
73
246
78
281
64
189
69
220
74
252
79 and over
295
680-001
2014 Printing