Fillable Bsa Health Form – Fill Out and Use

Part B

PHYSICAL EXAMINATION

Height____________ Weight ____________ % body fat___________ Meets height/weight limits Yes No

Blood pressure ___________ Pulse ____________

Individuals desiring to participate in any high-adventure activity or event in which emergency evacuation would take longer than 30 minutes by ground transportation will not be permitted to do so if they exceed the height/weight limits as documented in the table at the bottom of this page or if during a physical exam their health care provider determines that body fat percentage is outside the range of 10 to 31 percent for a woman or 2 to 25 percent for a man. Enforcing this limit is strongly encouraged for all other events, but it is not mandatory. (For healthy height/weight guidelines, visit www.cdc.gov.)

Allergies (to what agent, type of reaction, treatment): __________________________________________________________________________________________

______________________________________________________________________________________________________________________________________________________

I certify that I have, today, reviewed the health history, examined this person, and approve this individual for participation in:

Specify restrictions (if none, so state) ____________________________________________________________________________________________________________

________________________________________________________________________________________________________________________

Certiied and licensed health-care providers recognized by the BSA to perform this exam include physicians (MD, DO), nurse practitioners, and physician’s assistants.

This table is based on the revised Dietary Guidelines for Americans from the U.S. Dept. of Agriculture and the Dept. of Health & Human Services.

Part B Last name: _________________________________________ DOB: ___________________

Part C

Informed Consent and Hold Harmless/Release Agreement

I understand that participation in Scouting activities involves a certain degree of risk. I have carefully considered the risk involved and have given consent for myself and/or my child to participate in these activities. I understand that participation in these activities is entirely voluntary and requires participants to abide by applicable rules and standards of conduct. I release the Boy Scouts of America, the local council, the activity coordinators, and all employees, volunteers, related parties, or other organizations associated with the activity from any and all claims or liability arising out of this participation.

I approve the sharing of the information on this form with BSA volunteers and professionals who need to know of medical situations that might require special consideration for the safe conducting of Scouting activities.

In case of an emergency involving me or my child, I understand that every effort will be made to contact the individual listed as the emergency contact person. In the event that this person cannot be reached, permission is hereby given to the medical provider selected by the adult leader in charge to secure proper treatment, including hospitalization, anesthesia, surgery, or injections of medication for me or my child. Medical providers are authorized to disclose to the adult in charge Protected Health Information/ Conidential Health Information (PHI/CHI) under the Standards for Privacy of Individually Identiiable Health Information, 45 C.F.R. §§160.103, 164.501, etc. seq., as amended from time to time, including examination indings, test results, and treatment provided for purposes of medical evaluation of the participant, follow-up and communication with the participant’s parents or guardian, and/or determination of the participant’s ability to continue in the program activities.

Without restrictions.

With special considerations or restrictions (list) ____________________________________________________________________________________________

____________________________________________________________________________________________________________________________________________________

I hereby assign and grant to the local council and the Boy Scouts of America the right and permission to use and publish the photographs/ ilm/videotapes/electronic representations and/or sound recordings made of me or my child at all Scouting activities, and I hereby release the Boy Scouts of America, the local council, the activity coordinators, and all employees, volunteers, related parties, or other organizations associated with the activity from any and all liability from such use and publication.

I hereby authorize the reproduction, sale, copyright, exhibit, broadcast, electronic storage, and/or distribution of said photographs/ ilm/videotapes/electronic representations and/or sound recordings without limitation at the discretion of the Boy Scouts of America, and I speciically waive any right to any compensation I may have for any of the foregoing.

YesNo

I understand that, if any information I/we have provided is found to be inaccurate, it may limit and/or eliminate the opportunity for participation in any event or activity.

Participant’s name ______________________________________________________________________________________________________________________________

Participant’s signature ________________________________________________________________________________________________________________________

Parent/guardian’s signature ________________________________________________________________________________________________________

(if under the age of 18)

Date ________________________________________________

Attach copy of insurance card (front and back) here. If required by your state, use the space provided here for notarization.

Part C Last name: _________________________________________ DOB: ___________________

Rev. 9/2009