Fill Out Your Bsa Health Form
When engaging in high-adventure activities through the Boy Scouts of America (BSA), understanding the BSA Health Form is crucial for ensuring safety and preparedness. This comprehensive document serves several important functions, starting with the Informed Consent section, where participants acknowledge the potential risks involved in scouting activities. Additionally, it incorporates a Release Agreement that informs participants about their rights and the nature of medical care available in emergencies. Each participant is required to provide personal information such as their full name, date of birth, and any relevant health history, including existing medical conditions and allergies. Important health details, like height, weight, and emergency contact information, must be included to ensure adequate care can be provided if needed. Furthermore, a pre-participation physical by a qualified medical professional is necessary, verifying that individuals can safely take part in the selected activities. This section of the form addresses medical restrictions, allergies, and any contraindications for participation, creating a holistic view of a participant's health. With careful attention to these elements, the BSA Health Form helps build a secure environment for everyone involved, allowing scouts to focus on adventure while keeping their well-being front and center.
Bsa Health Example
Part A: Informed Consent, Release Agreement, and Authorization
A
Full name: ____________________________________________
Date of birth:__________________________________________
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
(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
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: __________________________________________________________________ |
2019 Printing
Part B1: General Information/Health History
Full name: ____________________________________________
Date of birth:__________________________________________
B1
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?
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No |
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Explain |
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Diabetes |
Last HbA1c percentage and date: |
Insulin pump: Yes £ No £ |
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Hypertension (high blood pressure) |
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Adult or congenital heart disease/heart attack/chest pain (angina)/ |
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heart murmur/coronary artery disease. Any heart surgery or |
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procedure. Explain all “yes” answers. |
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Family history of heart disease or any sudden |
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death of a family member before age 50. |
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Stroke/TIA |
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Asthma/reactive airway disease |
Last attack date: |
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Lung/respiratory disease |
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COPD |
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Ear/eyes/nose/sinus problems |
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Muscular/skeletal condition/muscle or bone issues |
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Head injury/concussion/TBI |
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Altitude sickness |
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Psychiatric/psychological or emotional difficulties |
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Neurological/behavioral disorders |
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Blood disorders/sickle cell disease |
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Fainting spells and dizziness |
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Kidney disease |
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Seizures or epilepsy |
Last seizure date: |
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Abdominal/stomach/digestive problems |
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Thyroid disease |
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Skin issues |
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Obstructive sleep apnea/sleep disorders |
CPAP: Yes £ No £ |
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List all surgeries and hospitalizations |
Last surgery date: |
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List any other medical conditions not covered above |
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2019 Printing
Part B2: General Information/Health History
Full name: ____________________________________________
Date of birth:__________________________________________
B2
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 |
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Medication
Food
DO YOU USE AN ASTHMA RESCUE YES NO
INHALER? Exp. date (if yes) ___________________________________
Yes |
No |
Allergies or Reactions |
Explain |
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Plants |
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Insect bites/stings |
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List all medications currently used, including any
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 |
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.
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No |
Had Disease |
Immunization |
Date(s) |
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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:_ _________________________________________________
2019 Printing
Part C:
This part must be completed by certified and licensed physicians (MD, DO), nurse practitioners, or physician assistants.
C
Full name: ____________________________________________
Date of birth:__________________________________________
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
Please fill in the following information:
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Yes |
No |
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Explain |
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Medical restrictions to participate |
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Yes |
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Allergies or Reactions |
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Explain |
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No |
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Allergies or Reactions |
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Explain |
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Medication |
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Plants |
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Food |
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Insect bites/stings |
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Height (inches) |
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Weight (lbs.) |
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BMI |
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Blood Pressure |
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Pulse |
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Normal |
Abnormal |
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Explain Abnormalities |
Examiner’s Certification |
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I certify that I have reviewed the health history and examined this person and find |
no contraindications for |
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Eyes |
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participation in a Scouting experience. This participant (with noted restrictions): |
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True |
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Explain |
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Ears/nose/throat |
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Meets height/weight requirements. |
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Lungs |
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Has no uncontrolled heart disease, lung disease, or hypertension. |
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Has not had an orthopedic injury, musculoskeletal problems, or orthopedic |
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surgery in the last six months or possesses a letter of clearance from his or her |
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orthopedic surgeon or treating physician. |
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Has no uncontrolled psychiatric disorders. |
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Abdomen |
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Has had no seizures in the last year. |
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Genitalia/hernia |
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Does not have poorly controlled diabetes. |
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If planning to scuba dive, does not have diabetes, asthma, or seizures. |
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Musculoskeletal |
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Examiner’s signature:_ _______________________________________ Date: _ _______________ |
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Neurological |
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Examiner’s printed name:_ _________________________________________________________ |
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Address:________________________________________________________________________ |
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Skin issues |
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City:_ ______________________________________State:_ ______________ ZIP code:_ _________ |
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Other |
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Office phone:____________________________________________________ |
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Height/Weight Restrictions
If you exceed the maximum weight for height as explained in the following chart and your planned
Maximum weight for height:
Height (inches) |
Max. Weight |
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Height (inches) |
Max. Weight |
Height (inches) |
Max. Weight |
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Height (inches) |
Max. Weight |
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60 |
166 |
65 |
195 |
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70 |
226 |
75 |
260 |
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61 |
172 |
66 |
201 |
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71 |
233 |
76 |
267 |
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62 |
178 |
67 |
207 |
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72 |
239 |
77 |
274 |
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63 |
183 |
68 |
214 |
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73 |
246 |
78 |
281 |
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64 |
189 |
69 |
220 |
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74 |
252 |
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79 and over |
295 |
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2019 Printing
Form Characteristics
| Fact Name | Fact Details |
|---|---|
| Informed Consent | The BSA Health Form requires participants to provide informed consent, acknowledging the risks involved in Scouting activities. |
| Emergency Contact | Participants must designate an emergency contact person, who will be contacted by medical providers in case of an emergency. |
| Protected Health Information | The form allows the sharing of medical information with authorized personnel to ensure safe participation in activities. |
| Release of Claims | Participants waive any claims for personal injury or loss against the BSA and its affiliates by signing the form. |
| Photo Release | Participants give permission for the BSA to use and publish photographs taken during events without compensation. |
| BB Device Usage | Approval for BB device use must be indicated, with the option to decline this participation noted explicitly. |
| Health History Requirement | The form requires a detailed health history, including existing medical conditions and allergies, to ensure safety. |
| Immunization Records | Participants must provide immunization dates, particularly for Tetanus, which is required within the last ten years. |
| Physical Examination | A certified medical professional must complete a physical examination section, certifying the participant's ability to engage in Scouting activities. |
| State Specific Compliance | The use of this form may be subject to state regulations, such as California Penal Code Section 19915(a) for minors using BB devices. |
Guidelines on Utilizing Bsa Health
Filling out the BSA Health form is essential for ensuring safety and preparedness for participants in scouting activities. Following these steps will ensure that all necessary information is provided accurately, helping officials to make informed decisions regarding care and participation.
- Complete Part A: Write your full name, date of birth, expedition or crew number, and your staff position, if applicable.
- Read the consent and authorization: Carefully review the informed consent, release agreement, and authorization sections. Understanding the associated risks and your rights here is essential.
- Provide emergency contact details: Fill in the emergency contact person's name and information. Specify what action should be taken if this person cannot be reached.
- List medical conditions: Identify any medical conditions or restrictions that apply to you or your child, if relevant. Indicate ‘None’ if there are no restrictions.
- Sign the form: To validate the information, sign and date the form at the designated spots for both the participant and the parent or guardian, if under 18.
- Complete Part B1 and B2: Fill in general information and health history. Include your age, gender, height, weight, and all relevant medical history.
- List allergies and medications: Indicate any allergies, current medications, and any special considerations for administering medications.
- Provide immunization history: Complete the immunization section by checking the required boxes and providing the necessary details for any immunizations received.
- Complete Part C: Schedule a physical examination with a certified physician or healthcare provider. They must review health history and complete their section of the form, certifying eligibility for participation.
- Attach insurance documentation: Include a photocopy of both sides of your health and accident insurance card if applicable.
What You Should Know About This Form
What is the purpose of the BSA Health form?
The BSA Health form is designed to ensure the safety and well-being of participants in Scouting activities. It collects important information about a participant’s health history, medical conditions, and emergency contact details. This information helps leaders manage any potential health risks during activities and to make informed decisions in case of medical emergencies.
Do I need to fill out the entire form for my child?
Yes, the entire form must be completed to ensure that all necessary information is available. Each section plays a crucial role in understanding a participant's health background. Providing accurate and comprehensive information helps leaders to adapt activities or take necessary precautions for your child’s safety. If your child has no restrictions or medical conditions, you can indicate that clearly in the form.
What should I do if my child has specific medical conditions?
If your child has any specific medical conditions, it is essential to detail them in the health history section of the form. This includes conditions like asthma, diabetes, or allergies. Be sure to include any medications your child takes and instructions for their use. This information helps caregivers respond appropriately to any medical needs or emergencies that may arise during Scouting activities.
Can the information on the BSA Health form be shared?
Yes, the information provided on the BSA Health form can be shared with medical providers, camp staff, and BSA volunteers who need to know about a participant's medical conditions. This sharing is done to ensure the safety of participants during activities. However, it is done in accordance with privacy regulations, and the information is kept confidential. You are authorizing this sharing by signing the form.
Common mistakes
Filling out the BSA Health form can seem straightforward, but many people make critical mistakes that can affect their participation. One common error is failing to provide complete and correct contact information. Participants often skip or overlook the emergency contact section, leaving important fields blank or filled incorrectly. This can delay critical communication during an emergency.
Another frequent issue is inaccuracies in health history. People sometimes forget to update their current medical conditions or treatments. It is essential to report any recent medical changes as this information helps medical personnel provide appropriate care if needed.
Many fail to attach a photocopy of their health insurance card. Not including this document means that the health providers may experience delays when attempting to verify coverage. Additionally, if a participant has no insurance, it’s crucial to clearly state this on the form, yet many neglect to do so.
Another error occurs with medication lists. Participants often list only prescription medications without mentioning over-the-counter drugs or supplements they also take. This oversight can lead to complications if a participant requires treatment during an activity.
In addition, some parents forget to sign the form, especially when it involves a youth participant. An unsigned form can lead to denial of participation, even if all other information is complete. Always ensure that signatures are provided where required, whether for youth or adults.
Another mistake relates to the communication of restrictions. Sometimes, necessary limitations regarding physical activity aren't fully documented. If participants have restrictions, clearly stating them in the designated area ensures that leaders are aware and can plan accordingly.
Finally, not reviewing the entire form for completeness and clarity before submission is a significant oversight. A last-minute check can catch missing information or typographical errors that could impact participation. Taking time to double-check can save everyone from unnecessary issues down the line.
Documents used along the form
The BSA Health form is a crucial document for participants in Scouting activities, providing necessary medical information and consent. In addition to this form, several other documents are commonly required to ensure the health and safety of all participants. Below is a list of these documents, along with brief descriptions of each.
- Emergency Contact Information Form: This document is used to designate emergency contacts in the event of an incident, ensuring that responsible adults can be reached quickly.
- Medical Insurance Information Form: Participants must provide details regarding their health insurance coverage, including the name of the insurance company and policy number, to facilitate medical care if needed.
- Parental Consent Form: This form serves to obtain permission from a parent or guardian for a child to engage in specific activities, especially those involving risk.
- Behavioral Contract: This document outlines the expected behavior and conduct of participants, as well as the consequences for violations, promoting a safe environment.
- Medications Authorization Form: Parents must complete this form to authorize the administration of medications, specifying any medications their child is allowed to receive during events.
- Health History Questionnaire: Participants provide comprehensive health histories, detailing past and present medical conditions that could affect their participation.
- Release of Liability Form: This form releases the organization from liability for injuries or accidents that may occur during activities, clarifying the risks involved.
- Photo Release Form: Parents or guardians sign this document to grant permission for photographs or videos of their child to be used in promotional materials.
- Pre-Participation Physical Examination Form: A healthcare provider must complete this form to certify that the participant is physically fit and has no specific medical restrictions that would interfere with participation.
Completing these forms assists in creating a safe and organized environment for all participants. Each document plays a vital role in addressing health concerns and ensuring effective communication among organizers, participants, and their families.
Similar forms
- Informed Consent Form: Like the BSA Health form, an informed consent form ensures that participants understand the risks involved in an activity. It requires participants to acknowledge their voluntary participation, similar to the health form's informed consent section, emphasizing the potential for personal injury and the importance of following safety protocols.
- Medical History Questionnaire: This document collects comprehensive information about an individual's past and present health conditions. Similar to the BSA Health form, it aims to identify any medical needs or restrictions that may affect participation, ensuring that appropriate measures can be taken to safeguard the health of all participants.
- Release of Liability Agreement: This agreement shares common ground with the BSA Health form by serving as a legal document where participants waive their right to sue for injuries. Both documents underscore the idea that individuals are taking on risks willingly and that the organization is not liable for any adverse outcomes during the activities.
- Emergency Contact Form: Both the BSA Health form and an emergency contact form collect details about whom to contact in case of an emergency. The BSA Health form identifies an emergency contact person, ensuring that medical providers can receive necessary information quickly, just as an emergency contact form ensures prompt notification of family members if an incident occurs.
Dos and Don'ts
Things to Do:
- Provide complete and accurate information in all sections of the BSA Health form.
- Review the form with your child to ensure they understand the risks associated with participation.
- List any medical restrictions clearly to ensure proper care and attention.
- Sign and date the form where indicated, including both participant and parent/guardian signatures if applicable.
- Attach a photocopy of both sides of your insurance card, if applicable.
Things to Avoid:
- Do not skip any sections of the form, as missing information may lead to participation issues.
- Avoid providing false information; inaccuracies can limit participation opportunities.
- Do not submit the form without the necessary signatures, especially for minors.
- Do not assume that sharing verbal information will suffice; ensure everything is documented.
- Do not forget to check expiration dates on medications and ensure sufficient quantities are provided.
Misconceptions
Here are eight common misconceptions about the BSA Health Form, along with clarifications to help you better understand its importance and requirements.
- Misconception 1: The BSA Health Form is optional for participation in events.
- Misconception 2: Health information is not shared with third parties.
- Misconception 3: I can skip the health history section if my child is healthy.
- Misconception 4: The form is only for youth participants.
- Misconception 5: The medical provider needs to evaluate my child every year.
- Misconception 6: Signing the form releases BSA from all liabilities.
- Misconception 7: If the form is missing information, it will still be accepted.
- Misconception 8: The Health Form is the only thing I need to prepare for BSA activities.
In reality, completing the BSA Health Form is mandatory for all participants to ensure safety and compliance with health regulations. It is a crucial document that helps organize a safe experience.
While the form does protect your information, it allows medical providers to share certain health details with staff involved in care during events. This is essential for emergencies and medical treatment.
Completing the health history section is still necessary, even if your child is healthy. This ensures that any changes in health are documented, and it provides leaders with the ability to monitor participant well-being.
The BSA Health Form is required for both youth and adult participants. Every person involved in activities must submit a completed form.
A physical examination by a healthcare provider is valid for up to 12 months. However, specific camps or activities may have different requirements, so verify based on the event you are attending.
While the form does include a release of liability, it does not exempt BSA from responsibilities pertaining to gross negligence. Participants are still protected under certain circumstances.
Any missing or inaccurate information can limit your child's participation. Ensure all sections are complete and accurate before submitting the form.
The form is critical, but you must also consider other preparations, such as reviewing event-specific guidelines and packing appropriate gear. Ensure a thorough understanding of all aspects of participation.
Key takeaways
- Informed Consent: Participants must acknowledge the risks involved in Scouting activities, including potential personal injury or death. It's essential to read this section carefully.
- Emergency Contact Information: Fill in accurate emergency contact details. If the primary contact can't be reached, medical providers have permission to treat the participant.
- Medical History: Participants should disclose any existing medical conditions. Complete honesty is crucial, as inaccurate information may limit participation.
- Signatures Required: A participant’s signature is needed. For individuals under 18, a parent or guardian must also sign, indicating consent for participation.
- Health Insurance Information: It is necessary to provide details of health insurance coverage. If a participant lacks insurance, this must be indicated clearly.
- Restrictions: If there are any restrictions on a participant’s activities, these should be listed. This helps leaders ensure the safety and well-being of all participants.
- Medication Instructions: Participants must bring sufficient medication for the duration of the program, kept in original containers. Be sure medications are not expired.
- Pre-Participation Physical: A health evaluation by a licensed medical professional is required to confirm that participants are fit for activities.
- Photograph Release: The form includes a clause that allows the BSA to use photos of participants for promotional purposes. Granting this permission is part of the process.
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