Bsa 680 001 – Fill Out and Use This PDF

The BSA 680-001 form serves as a comprehensive document necessary for participation in high-adventure activities organized by the Boy Scouts of America. It encompasses three key components: informed consent, release agreement, and authorization; general information/health history; and a pre-participation physical. Designed to ensure all participants are adequately prepared and informed about the risks involved, this form is pivotal for scouting events that push the physical, mental, and emotional boundaries of participants. To undertake an unforgettable adventure safely, ensure you complete the BSA 680-001 form by clicking the button below.

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Bsa 680 001 PDF Details

The BSA 680-001 form is a comprehensive document encompassing informed consent, medical history, and authorization vital for participants in Boy Scouts of America high-adventure activities. The form is divided into three parts, with Part A focusing on informed consent and release agreement, outlining the understanding of risks involved in Scouting activities and the authorization for emergency medical treatment. It also includes provisions for the use of photographs and videos taken during Scouting events. The section regarding BB device usage highlights the document’s attention to specific activities' risks and parental control over their child's participation. Part B details the participant's health history, medication information, immunization records, and health insurance coverage, ensuring that all medical concerns are transparent and known to event coordinators for the safety of the participants. Finally, Part C, which must be completed by a licensed healthcare provider, certifies the participant's physical condition and any medical restrictions that might limit their ability to engage in certain activities. This part serves as a crucial checkpoint to prevent health risks during physically demanding programs. Altogether, the BSA 680-001 form plays an essential role in safeguarding participant health and legal interests, facilitating a safe and informed environment for high-adventure scouting experiences.

Question	Answer
Form Name	Bsa 680 001
Form Length	6 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	1 min 30 sec
Other names	boy scout a and b form, bsa medical form pdf, boy scout physical form, bsa medical form

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Part A: Informed Consent, Release Agreement, and Authorization

Full name: ___________________________________________

Date of birth: _________________________________________

High-adventure base participants:

Expedition/crew No.: _______________________________________________

or staff position:___________________________________________________

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.

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.

Every person who furnishes any BB device to any minor, without the express or implied permission of the parent or legal guardian of the minor, is guilty of a misdemeanor. (California Penal Code

Section 19915[a]) My signature below on this form indicates my permission.

I give permission for my child to use a BB device. (Note: Not all events will include BB devices.)

Checking this box indicates you DO NOT want your child to use a BB device.

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 Scout Ranch, Philmont Training Center, Northern Tier, Sea Base, or the Summit Bechtel Reserve, I have also read and understand the supplemental risk advisories, including height and weight requirements and restrictions, and understand that the participant will not be allowed to participate in applicable high-adventure programs if those requirements are not met. The participant has permission to engage in all high-adventure activities described, except as 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)

Complete this section for youth participants only:

Adults Authorized to Take Youth to and From Events:

You must designate at least one adult. Please include a phone number.

Name: _________________________________________________________________	Name: _________________________________________________________________
Phone: _________________________________________________________________	Phone: _________________________________________________________________

Adults NOT Authorized to Take Youth to and From Events:

Name: _________________________________________________________________	Name: _________________________________________________________________
Phone: _________________________________________________________________	Phone: _________________________________________________________________

680-001

2019 Printing

Part B1: General Information/Health History

Full name: ___________________________________________

Date of birth: _________________________________________

High-adventure base participants:

Expedition/crew No.: _______________________________________________

or staff position:___________________________________________________

Age: ____________________________ Gender: __________________________ Height (inches): ___________________________ Weight (lbs.): ____________________________

Address: _________________________________________________________________________________________________________________________________________

City: ___________________________________________State: ____________________________ ZIP code: __________________ Phone: ______________________________

Unit leader: ____________________________________________________________________________ Unit leader’s mobile #:_________________________________________

Council Name/No.: _______________________________________________________________________________________________________Unit No.: ____________________

Health/Accident Insurance Company: ________________________________________________________ Policy No.: ___________________________________________________

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					Explain
		Diabetes	Last HbA1c percentage and date:				Insulin pump: Yes  No 

		Hypertension (high blood pressure)

		Adult or congenital heart disease/heart attack/chest pain (angina)/
		heart murmur/coronary artery disease. Any heart surgery or
		procedure. Explain all “yes” answers.

		Family history of heart disease or any sudden heart-related
		death of a family member before age 50.

		Stroke/TIA

		Asthma/reactive airway disease	Last attack date:

		Lung/respiratory disease

		COPD

		Ear/eyes/nose/sinus problems

		Muscular/skeletal condition/muscle or bone issues

		Head injury/concussion/TBI

		Altitude sickness

		Psychiatric/psychological or emotional difficulties

		Neurological/behavioral disorders

		Blood disorders/sickle cell disease

		Fainting spells and dizziness

		Kidney disease

		Seizures or epilepsy	Last seizure date:

		Abdominal/stomach/digestive problems

		Thyroid disease

		Skin issues


		Obstructive sleep apnea/sleep disorders	CPAP: Yes		No	

		List all surgeries and hospitalizations	Last surgery date:

		List any other medical conditions not covered above

680-001

2019 Printing

Part B2: General Information/Health History

Full name: ___________________________________________

Date of birth: _________________________________________

High-adventure base participants:

Expedition/crew No.: _______________________________________________

or staff position:___________________________________________________

Allergies/Medications

DO YOU USE AN EPINEPHRINE YES  NO

AUTOINJECTOR? Exp. date (if yes) ___________________________

Are you allergic to or do you have any adverse reaction to any of the following?

Yes	No	Allergies or Reactions	Explain

Medication

Food

DO YOU USE AN ASTHMA RESCUE YES  NO

INHALER? Exp. date (if yes) ___________________________________

Yes	No	Allergies or Reactions	Explain

		Plants


		Insect bites/stings
		Insect bites/stings

List all medications currently used, including any over-the-counter medications.

Check here if no medications are routinely taken.

If additional space is needed, please list on a separate sheet and attach.

Medication

Dose

Frequency

Reason

 YES NO

Non-prescription medication administration is authorized with these exceptions: ________________________________________________________________

Administration of the above medications is approved for youth by:

_______________________________________________________________________ / _______________________________________________________________________

Parent/guardian signature

MD/DO, NP, or PA signature (if your state requires signature)

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. Tetanus immunization is required and must have been received within the last 10 years. If you had the disease, check the disease column and list the date. If immunized, check yes and provide the year received.

Yes	No	Had Disease	Immunization	Date(s)

Tetanus

Pertussis

Diphtheria

Measles/mumps/rubella

Polio

Chicken Pox

Hepatitis A

Hepatitis B

Meningitis

Influenza

Other (i.e., HIB)

Exemption to immunizations (form required)

Please list any additional information about your medical history:

_________________________________________

DO NOT WRITE IN THIS BOX.

Review for camp or special activity.

Reviewed by: ___________________________________________

Date: _________________________________________________

Further approval required: Yes  No

Reason: _______________________________________________

Approved by:____________________________________________

Date: _________________________________________________

680-001

2019 Printing

Part C: Pre-Participation Physical

This part must be completed by certified and licensed physicians (MD, DO), nurse practitioners, or physician assistants.

Full name: ___________________________________________

Date of birth: _________________________________________

High-adventure base participants:

Expedition/crew No.: _______________________________________________

or staff position:___________________________________________________

You are being asked to certify that this individual has no contraindication for participation in 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. You can also visit www.scouting.org/health-and-safety/ahmr to view this information online.

Please fill in the following information:

Yes

Explain

Medical restrictions to participate

Yes

Allergies or Reactions

Explain

Yes

Allergies or Reactions

Explain

Medication

Plants

Food

Insect bites/stings

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

Eyes

participation in a Scouting experience. This participant (with noted restrictions):

True

False

Explain

Ears/nose/throat

Meets height/weight requirements.

Lungs

Has no uncontrolled heart disease, lung disease, or hypertension.

Has not had an orthopedic injury, musculoskeletal problems, or orthopedic

Heart

surgery in the last six months or possesses a letter of clearance from his or her

orthopedic surgeon or treating physician.

Has no uncontrolled psychiatric disorders.

Abdomen

Has had no seizures in the last year.

Genitalia/hernia

Does not have poorly controlled diabetes.

If planning to scuba dive, does not have diabetes, asthma, or seizures.

Musculoskeletal

Examiner’s signature: _______________________________________ Date: _______________

Neurological

Examiner’s printed name: _________________________________________________________

Address: _______________________________________________________________________

Skin issues

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)	Max. Weight

60	166	65		195	70	226	75		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

2019 Printing

	High-Adventure Risk Advisory to	Summit Bechtel Reserve
	Health-Care Providers and Parents

	Phone: 304-465-2800 Website: www.summithighadventure.org

The Summit Bechtel Family National Scout Reserve requires that the following supplemental information be shared with the parents and/or guardians and examining health-care providers of every participant. Participants who cannot meet these guidelines will be sent home at their own expense.

The Summit. Activities at the Summit require a certain level of fitness and some can be very physically, mentally, and emotionally demanding. The programs can include mountain biking, BMX biking, skateboarding, rock climbing, zip lines, challenge courses, shooting, archery, whitewater rafting, and kayaking. Depending on the program(s) you select, you will need to arrive at the Summit physically prepared to participate in those activities. The average walk is 5–7 miles a day on uneven terrain with significant changes in elevation. The heat index often reaches almost 100 degrees in the summer. Be prepared!

It is recommended that every participant review information about the Summit Bechtel Reserve at www.summitbsa.org and learn about the program activities that have been selected for participation. Answers to many frequently asked questions can be found at the Summit website. Additional questions can be emailed to summit.program@scouting.org, or you may call 304-465-2800.

Allergy or Anaphylaxis. Participants who have had an anaphylactic reaction due to any cause MUST contact the Summit Bechtel Reserve before arrival. If you are allowed to participate, you will be required to have appropriate treatment with you. The individual and at least one other member of the group must know how to administer the treatment. If you do not bring appropriate treatment with you, you will be required to buy it before you will be allowed

to participate.

Asthma. Asthma must be well-controlled before participating. This means:

1)the use of a rescue inhaler (albuterol) less than two times per week (except

use for the prevention of exercise-induced asthma); 2) nighttime awakenings for asthma symptoms less than two times per month. Well-controlled asthma may include the use of long-acting bronchodilators, inhaled steroids, or oral medications such as Singulair. You may not be allowed to participate if: 1) you have asthma not controlled by medication; or 2) you have been hospitalized/gone to the emergency room to treat asthma in the past six months; or 3) you have needed treatment by oral steroids (prednisone) in the past six months. You must bring an ample supply of your medication and a spare rescue inhaler that are not expired. At least one other member of the crew should know how to use the rescue inhaler. Any person who has needed treatment for asthma in the past three years must carry a rescue inhaler on the trek. If you do not bring a rescue inhaler, you must buy one before you will be allowed to participate.

Immunizations. Each participant must have received a tetanus immunization within the last 10 years. Recognition will be given to participants who do not have a specific immunization because of philosophical, political, or religious beliefs. In such a situation, the Immunization Exemption Request form should be obtained by emailing summit.program@scouting.org.

Seizure Disorder. A seizure disorder or epilepsy does not exclude an individual from participation; however, the disorder must be well controlled with medication. A well-controlled disorder is one in which a year has passed without a seizure. Exceptions to this guideline may be considered on an individual basis.

Recent Musculoskeletal Injuries or

Orthopedic Surgery. Participants at the Summit will put a great deal of strain on their joints and skeletal structure. Individuals with significant musculoskeletal problems (including back problems) or orthopedic surgery within the last six months must have a letter of clearance from their treating physician to be considered for approval. These individuals should contact the Summit in advance for approval to participate.

Psychological and Emotional Difficulties.

Medications for these issues must never be stopped prior to or during participation at the Summit. Experience has demonstrated that these issues can be exacerbated when a participant is under stress from physical and mental challenges.

Diabetes. Both the individual with diabetes and one other person in the group must be able to recognize the signs and symptoms of high and low blood sugar. An insulin-dependent person who has been newly diagnosed or who has undergone a change in their delivery system must have a letter from their treating physician to participate. A recent HbA1c within the last six months is required for diabetic participants.

Hypertension (High Blood Pressure). High blood

pressure should be well controlled with medication. Medication should be continued as prescribed while participating at the Summit. Individuals should have a blood pressure of less than 140/90 to participate.

Medication. Each participant who needs medication must bring enough medicine for the duration of the trip, and that medicine must not have expired. Taking 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 responsibility for ensuring a youth takes necessary medication in accordance with the appropriate schedule. Medications should be secured in locked storage, according to National Camp Accreditation Program Standard HS-08, except for medications carried by the individual for emergent conditions (inhalers, EpiPens, etc.). Participants should consider bringing two or three supplies of vital medication. Participants with allergies that have resulted in severe reactions or anaphylaxis must bring an EpiPen that has not expired. Summit-supplied medications shall be administered and/or dispensed in accordance with preapproved medical procedures. Participants will be charged for maintenance medications not brought to the Summit that are supplied by the Summit Health Lodge.

680-001 October 2019

	High-Adventure Risk Advisory to	Summit Bechtel Reserve
	Health-Care Providers and Parents

	Phone: 304-465-2800 Website: www.summithighadventure.org

Recommendations for Chronic Illnesses.

Adults or youth with any of the following conditions should undergo an evaluation by a physician before considering participation at the Summit.

1.	Chest pain, myocardial infarction (heart attack), or family history of heart
	disease in any person before age 50
2.	Congestive heart failure
3.	Heart surgery, including angioplasty (balloon dilation), to treat blocked blood
	vessels or place stents
4.	Stroke or transient ischemic attacks (TIAs)
5.	High blood pressure
6.	Claudication (leg pain with exercise, caused by hardening of
	the arteries)

Participants age 21 and older who exceed the maximum acceptable weight limit for their height at the Summit medical recheck WILL NOT be permitted to participate in offsite high-adventure programming, but they will have the option of participating in onsite programming if it is available. Summit staff will use their judgment to determine whether those under age 21 who exceed the maximum acceptable weight for their height can participate. The Summit may accept up to 20 pounds over the maximum; however, such exceptions are not made automatically, and discussion with Summit staff in advance will be required by calling

304-465-2800. Please consult the individual program information for weight restrictions due to equipment.

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.

7.	Diabetes
8.	Smoking
9.	Excessive weight

Physical exertion at the Summit could precipitate either a heart attack or a stroke in someone who is susceptible. Individuals with a history of any of the conditions listed above should consult their physician to see whether participating in vigorous activities like those at the Summit could exacerbate their condition.

Weight Limits. Weight limit guidelines are used because individuals who are overweight have a greater risk of heart disease, high blood pressure, stroke, altitude sickness, sleep problems, and injuries. These guidelines are for all

Height (inches)

Max. Weight

60166

61172

62178

63183

64189

65195

66201

67207

68214

69220

Height (inches)

Max. Weight

70226

71233

72239

73246

74252

75260

76267

77274

78281

79 and over

295

Scouting high-adventure activities. Each participant’s weight must be at or less than the maximum acceptable weight in the height/weight chart. Anyone exceeding the maximum weight for their height will require further review by the Summit.

Summit Approval. The staff and/or staff physicians reserve the right to deny participation of any individual on the basis of medical history and/or a physical examination. Each individual participant is subject to a medical recheck at the Summit if indicated.

680-001 October 2019

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You have to prepare the With appreciation of the dangers, NOTE Due to the nature of programs, List participant restrictions if, None, I understand that if any, Participants signature Date, Parentguardian signature for youth, Complete this section for youth, You must designate at least one, Name, and Name field with the essential particulars.

Identify the main information about the Adults NOT Authorized to Take, Name, Name, Phone, Phone, and Printing box.

You have to define the rights and obligations of all parties in section Part B General InformationHealth, Full name, Highadventure base participants, Date of birth, Expeditioncrew No, or staff position, Age Gender Height inches Weight, Address, City State ZIP code Phone, Unit leader Unit leaders mobile, Council NameNo Unit No, HealthAccident Insurance Company, Please attach a photocopy of both, In case of emergency notify the, and Name Relationship.

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