Microsoft word - 2010 5 health_form_instructions_2010-02-18

BSA Health and Medical Record 1. Complete Scout’s Last name/ Date of Birth/Allergies and emergency contact phone number (side of form). 2. Part A which includes general information (Social Security Number is Optional), Unit Leader (Ed Davey), Council name (HOAC), Health insurance company & policy number, emergency contact & alternate emergency contact information, medical history, allergies, immunizations (Provide dates – year only is adequate / “current” is not sufficient) and medications 3. Part B - Required to be completed for summer camp attendees only - Required to be completed by Health care practitioner - Informed Consent Hold and Harmless/Release Agreement Check either -Without Restrictions or -With special considerations/restrictions (List any special considerations or restrictions if applicable) Check either -Yes or - No Note: -Without Restrictions and -Yes are the typical boxes marked - Complete section regarding Adults who are/are not authorized to take your Scout - Complete Participants name, Participant’s signature, Parent’s/Guardian’s Signature and date Optional, but encouraged: Notarization of Parent’s/guardian’s signature 5. Provide photocopy of both sides of current health insurance card Note: - Completion and submission of a BSA Health/Medical Record - Parts A & C is necessary in order to participate in BSA/Troop activities (camping, etc.) & should be turned in to the Troop Health/Safety Coordinator as soon as these parts are completed. BSA Health/Medical Record - Part B can be turned in separately and at a later date than Parts A & C, but must be completed & submitted to the Troop prior to summer camp. Authorization for Administering of Medications 1. Complete Scout’s name (top of form) 2. Check either: -No Medications are to be given or -Authorize administration of medications as indicated 3. Sign and date 4. Circle any or all of the listed Over-The-Counter Medications that can be administered to your scout for mild discomfort. Note: List any over-the-counter medications that are not specifically indicated and are being provided to be dispensed to your Scout in the “Medication” sections at the bottom of this form (i.e. Prilosec OTC, Dramamine, etc.) 5. Complete “Strength” and “Frequency” of any Over-The-Counter medications that can be administered (Default answers are listed in parenthesis and can be circled in lieu of entering them in the blanks). 6. Complete “Any Special Reason for Taking this Medication” if applicable. 7. Complete a “Medication” section for each medication that is currently being taken by the Scout and would need to be dispensed during a campout, etc. 8. Attach additional pages for “Medications” if necessary. Troop 225 Emergency Contact form 1. Complete date (upper right corner of form). 2. Please attach photo of Scout, if available. 3. Complete entire form noting emergency contact phone numbers, persons authorized to or prohibited from picking up your Scout from an event and any allergies/known medical conditions. Note: All Health/Safety forms should be turned in to the Health and Safety Coordinator as soon as possible. Contact the Troop Health and Safety Coordinator with any questions or for additional information. Instructions for completing Health/Safety forms - Troop 225 Note: Scouts who participate in High Adventure campouts need special health forms to take part in those activities. See your High Adventure Leader for additional information.

Source: http://troop225bsa.org/pdf/health_form_instructions.pdf