Free Bsa 680 001 Form in PDF

Free Bsa 680 001 Form in PDF

The BSA 680-001 form is a critical document for participants in Boy Scouts of America high-adventure activities, encompassing sections like informed consent, medical history, and permission for emergency medical treatment. This comprehensive form serves not only as a release agreement but also as an authorization for medical care in situations where the participant cannot provide consent due to the nature of the injury or emergency. As these activities carry inherent risks, the form requires careful consideration and thorough completion to ensure the safety and preparedness of all involved. For a detailed guide on how to accurately fill out the BSA 680-001 form, click the button below.

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The Boy Scouts of America (BSA) Form 680-001 stands as a critical document designed to ensure the safety and preparedness of participants in Scouting activities, particularly those involving high-adventure bases. Comprising of several parts, it addresses a broad scope of necessities including informed consent, release agreement, authorization for medical treatment, a comprehensive health history, and medication management. Participants, or their guardians in the case of minors, must acknowledge the inherent risks of the activities, grant permissions for emergency medical treatment, and release the BSA from liability for personal injury, death, or property loss. Furthermore, this form delves into detailed medical information, ensuring participants are physically and mentally prepared for the demanding nature of these adventures, and mandates reporting of any medical conditions that could impact their participation. The inclusion of immunization records, along with specifics about medication usage, allergies, and recent surgeries, enables a thorough medical review by licensed professionals prior to engagement. Importantly, the form also requires disclosure of any adults authorized or not authorized to transport youth participants, highlighting the BSA’s commitment to the safety and well-being of its members at every turn. This comprehensive approach ensures that all participants can undertake Scouting activities with an understanding of the risks, preparedness for the physical demands, and safeguards against preventable health issues, thereby fostering a safer and more inclusive environment for all involved.

Preview - Bsa 680 001 Form

Part A: Informed Consent, Release Agreement, and Authorization

A

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: _________________________________________

B1

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: _________________________________________

B2

High-adventure base participants:

Expedition/crew No.: _______________________________________________

or staff position:___________________________________________________

Allergies/Medications

DO YOU USE AN EPINEPHRINEYES 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 RESCUEYES NO

INHALER? Exp. date (if yes) ___________________________________

 

Yes

 

No

Allergies or Reactions

Explain

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Plants

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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.

C

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

 

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Explain

 

 

 

Medical restrictions to participate

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Yes

 

 

No

 

 

Allergies or Reactions

 

 

 

 

Explain

 

 

 

 

 

 

Yes

 

 

 

No

 

 

 

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

Document Specs

Fact Name Description
Purpose of the Form The BSA 680-001 form serves as an Informed Consent, Release Agreement, and Authorization for participants in Scouting activities, especially those engaging in high-adventure bases, to ensure they understand the risks involved and to document medical information and emergency contacts.
Components of the Form It consists of three main parts: Part A covers Informed Consent and Release Agreement, Part B collects General Information/Health History, and Part C requires a Pre-Participation Physical to be completed by a certified medical professional.
Immunization and Medication Information Participants are required to disclose their immunization history, particularly tetanus within the last 10 years, and provide detailed information on any medications being taken, including the dosage and frequency, to ensure proper care during the activities.
Governing Laws for Specific States For residents of California participating in activities involving BB devices, the form highlights the need for permission under California Penal Code Section 19915(a), showcasing the inclusion of state-specific legal requirements within the form's consent process.

Instructions on Writing Bsa 680 001

Once you've decided to participate in a Scouting adventure that requires filling out the BSA 680-001 form, it's essential to complete it thoroughly to ensure safety and proper care during the activities. This form is a comprehensive document that gathers detailed personal, health, and medical information for participants engaging in high-adventure activities. It’s designed to safeguard participants by informing leaders and medical personnel about any conditions that require attention, ensuring everyone is prepared for a safe and enjoyable experience. Below are the steps to fill out the form correctly.

  1. Start with Part A: Informed Consent, Release Agreement, and Authorization. Fill in the participant's full name and date of birth at the top.
  2. If participating in a high-adventure base, include the Expedition/crew number or staff position.
  3. Read the informed consent carefully. It outlines the risks involved in scouting activities and requires your consent to participate.
  4. Decide if you are comfortable giving permission for your child to use a BB device, and check the appropriate box.
  5. For youth participants, list any restrictions related to the programs or activities in the space provided.
  6. The participant and parent or guardian (if the participant is under 18) must sign and date the bottom of Part A to indicate understanding and agreement.
  7. In Part B1: General Information/Health History, enter the participant's general information again, including full name and date of birth.
  8. Provide details about your health/accident insurance, including attaching a photocopy of the insurance card. If not insured, write “none”.
  9. Fill in the emergency contact information, including name, relationship, address, and phone numbers.
  10. Under Health History, accurately answer questions regarding past and current medical conditions, including details for any "yes" responses.
  11. In Part B2: Allergies/Medications, specify if you use an epinephrine autoinjector or asthma rescue inhaler and note the expiration dates.
  12. List all allergies and reactions, then detail all medications currently being used, including over-the-counter ones.
  13. Consent to non-prescription medication administration as per the directions given, with signatures from a parent/guardian and a health professional if required.
  14. Update the immunization section with the most current dates for the listed vaccinations.
  15. Part C must be completed by a certified and licensed healthcare provider. It involves a physical check-up to clear the participant for the adventure. The healthcare provider will enter medical restrictions, allergy information, physical measurements, blood pressure, pulse, and provide an overall certification of fitness for participation.
  16. If applicable, refer to the height and weight restrictions and ensure compliance to participate in high-adventure activities.
  17. Review any additional high-adventure risk advisories provided towards the end of the form, especially if participating at the Summit Bechtel Reserve, for specific health guidelines and requirements.

After completing all the sections, review the form to ensure accuracy and completeness before submission. Hand it over to the scout leader or the person in charge of the event or program. Proper completion of the BSA 680-001 form plays a crucial role in ensuring a safe and memorable experience for all participants involved in Scouting's high-adventure activities.

Understanding Bsa 680 001

What is the BSA 680-001 form used for?

The BSA 680-001 form is a comprehensive health and medical record used by the Boy Scouts of America (BSA) for participants involved in various scouting activities, particularly those engaging in high-adventure programs. It serves several critical purposes, including collecting informed consent, a medical history review, an authorization for emergency treatment, and permission for administering prescribed medications. It helps ensure that scouts are physically capable and properly cared for in the event of a medical emergency during scouting events.

Who needs to complete the BSA 680-001 form?

Any participant, youth or adult, planning to engage in BSA activities, especially high-adventure base experiences, must complete the BSA 680-001 form. This includes scouts attending Philmont Scout Ranch, Northern Tier, Sea Base, the Summit Bechtel Reserve, or any other scouting event where physical activity and outdoor exposure are involved. It's necessary for ensuring the safety and well-being of all participants through a thorough understanding of their medical conditions and limitations.

What information is required on the BSA 680-001 form?

The BSA 680-001 form is divided into three parts: Part A, which includes informed consent, release agreement, and authorization; Part B, which covers general information and health history, including allergies, medications, and immunization records; and Part C, a pre-participation physical that must be completed by a certified and licensed health-care professional. Participants are also asked about any dietary restrictions, current and past health conditions, and emergency contact information.

Is it mandatory to disclose all health conditions on the BSA 680-001 form?

Yes, full disclosure of all health conditions, no matter how minor they may seem, is mandatory when completing the BSA 680-001 form. This information is crucial for the safety of the participant, as it allows scouting leaders and medical staff to provide appropriate care and make informed decisions in case of an emergency. Failure to disclose all health information can lead to severe consequences and may restrict participation in certain activities.

How often does the BSA 680-001 form need to be updated or renewed?

The BSA 680-001 form must be updated annually or more frequently if there are significant changes in the participant's health status. Keeping health records current ensures that all information is accurate in case of an emergency and that participants are physically fit for the scouting activities they intend to join throughout the year.

What happens if I do not want my child to use a BB device during scouting activities?

If a parent or guardian does not wish for their child to use a BB device during scouting events, they can indicate this preference directly on the BSA 680-001 form. A specific section allows parents and guardians to opt-out of allowing their child to participate in activities involving BB devices by checking the corresponding box. This ensures that the child's participation in scouting activities aligns with the parent or guardian's comfort and safety preferences.

Common mistakes

Filling out the BSA 680-001 form, which encompasses informed consent, a release agreement, and authorization for participation in scouting activities, requires careful attention to detail. One common mistake is not properly completing the full name and date of birth sections under both Part A and Part B. These fundamental details are critical for identifying the participant throughout the scouting event or activity.

Another frequent oversight occurs in the health history section of the form. Here, participants often fail to disclose significant medical conditions or past treatments that could impact their ability to safely engage in certain scouting activities. This omission could not only endanger the participant but also put the entire group at risk.

Participants sometimes neglect to include accurate emergency contact information. In the event of an emergency, scouting leaders rely on this information to quickly get in touch with someone who can make medical decisions for the participant. Ensuring that the emergency contact details are current and correct is therefore imperative.

Another mistake involves misunderstanding or not properly acknowledging the informed consent section. This part of the form is crucial, as it outlines the risks associated with participation in scouting activities. Participants must carefully read and understand this section to ensure they are comfortable with the level of risk before consenting to partake in the activities.

The section regarding medications is also often inaccurately completed. Participants sometimes forget to list all medications they are currently taking, including over-the-counter medicines. Given that some activities may impact the efficacy or necessity of certain medications, accurate and detailed information in this section is vital.

A common error in the authorization parts of the form is related to the use of photographs, film, and electronic representations. Participants or their guardians might overlook giving or denying permission for the use of such materials, which are often used for promotional or educational purposes by the BSA.

Regarding the transportation section, one might fail to designate authorized adults for dropping off and picking up youth participants. This is critical for ensuring the safety and security of participants in getting to and from scouting events.

Last but not least, the mistake of not properly completing the section on allergies or dietary restrictions in Part B2. Participants must clearly identify any food, medication, or environmental allergies, along with any adverse reactions they have experienced. This information is essential for scouting leaders to manage potential exposure to allergens and ensure participants' well-being during events.

Documents used along the form

Fulfilling the requirements for Scouting activities often involves more than just completing the BSA 680-001 form. This form is a comprehensive document designed for the preparation and safety of participants in BSA high-adventure programs, making sure they are fit and have consent to engage in activities. Alongside it, however, various other documents and forms are typically needed to ensure a participant is thoroughly prepared and protected. Here's an overview of these documents:

  • Medical Insurance Card: A photocopy of both sides of the participant’s medical insurance card is essential for verifying insurance coverage in case of a medical emergency.
  • Medication List: A detailed list of medications, including dosages and the names of prescribing doctors, ensures that the health care providers at BSA activities are fully informed of the participant's medical needs.
  • Immunization Records: Providing a record of the participant’s immunizations, especially a recent tetanus shot, is crucial for participation. Some activities might require additional vaccinations.
  • Activity Consent Forms: Specific activities might require their own consent forms in addition to the general consent provided in the BSA 680-001 form. These consents cover the risks associated with particular adventures or outings.
  • Special Dietary Needs Form: If a participant has dietary restrictions due to health, religious beliefs, or personal choices, completing a form to communicate these needs ensures proper accommodation during activities.
  • Emergency Contact Information: While the BSA 680-001 form does request emergency contact information, an additional, more detailed form might be used by some councils or troops for more comprehensive planning.
  • Height and Weight Chart: For high-adventure bases, a height and weight chart may need to be reviewed and signed off, confirming that participants meet the physical requirements for safe participation.

Together, these documents support the information provided in the BSA 680-001 form, rounding out the participant's health and safety profile. They play a critical role in preparing for a successful and safe scouting experience. Ensuring these forms are correctly filled out and submitted in a timely fashion can significantly enhance the overall effectiveness of the program's preparatory steps.

Similar forms

The BSA 680-001 form is closely akin to other documents that necessitate the collection of participant information, health history, and consent for various activities, each serving a similar but distinct purpose within different contexts.

Firstly, the BSA 680-001 form shares similarities with school physical examination forms used across the United States. These forms commonly require a comprehensive health history and a physician's evaluation to certify that the student is fit for participation in school sports and physical education classes. Like the BSA form, they ensure that participants are physically and medically prepared for the activities they will engage in, thereby minimizing health risks associated with such participation.

Secondly, medical consent forms used in healthcare settings for minor patients bear resemblance to this Scouting form. These documents typically encompass permission for treatment, information on the risks and benefits of proposed procedures, and an acknowledgment of understanding from the patient or guardian. Both set of forms serve to ensure informed consent is given before any medical or surgical intervention begins.

Thirdly, camp registration forms for various youth camps outside the Boy Scouts also require detailed health information, emergency contacts, and permissions for activities. They might not include the specific high-adventure activity advisories present in the BSA form but similarly ensure that camp officials are aware of any medical conditions or limitations that could affect participation in camp activities.

Fourthly, consent forms for international student travel programs are similar to the BSA form in that they include medical information, emergency contacts, and releases for participation. However, they also often require information about passports, visas, and other travel-specific details, emphasizing the legal and medical preparedness for international travel.

The fifth example includes event liability waiver forms often seen in sports and recreational activities outside of the Scouting world. These waivers include participant agreements to not hold the organization liable for injuries as a result of participating, which mirrors the release and waiver of liability section within the BSA form, albeit usually without the detailed medical information section.

Sixth, athletic pre-participation examination forms, akin to the school physical examination documents but more focused on competitive sports, both school-affiliated and independent leagues, require health histories and medical clearances from healthcare providers, ensuring athletes are safe to compete.

Seventh, adventure sports companies that offer activities like zip-lining, whitewater rafting, or rock climbing often use forms similar to the high-adventure sections of the BSA 680-001 form. These documents assess participants' health and physical condition to ensure safety during demanding physical activities, requiring medical clearance and risk acknowledgment.

Lastly, emergency medical authorization forms found in various settings, from educational institutions to independent youth organizations, parallel the emergency contact and authorization sections of the BSA form. They ensure that in the event of a medical emergency, care can be provided promptly and according to the guardian's stipulations.

Dos and Don'ts

Filling out the BSA 680-001 form is crucial for ensuring a safe and prepared participation in Scouting activities, particularly those that involve high adventure bases. It's important to approach this task with care, ensuring that all information is accurate and comprehensive. Here are some do's and don'ts to guide you through the process:

Do's:

  1. Review and understand the risks: Before filling out the form, thoroughly read the informed consent, release agreement, and authorization sections to fully understand the activities' risks and requirements.
  2. Provide detailed health information: In parts B1 and B2, fill in every section about health history, allergies, medications, and immunizations with as much detail as possible. This information is critical for ensuring participant safety.
  3. Ensure accuracy of medical information: Double-check all medical details, including medication dosages, frequency, and any health conditions. Accuracy here can prevent any miscommunication in case of an emergency.
  4. Include up-to-date contact information: Make sure that the emergency contact information is current and includes individuals who can be readily contacted during the scouting events.

Don'ts:

  1. Leave sections incomplete: Do not skip any sections, especially those related to health history and authorized adults for pickup. Incomplete information could lead to issues during scouting activities.
  2. Forget to sign and date the form: The participant's and, if under 18, the parent or guardian's signatures are mandatory. Forgetting to sign could invalidate the form.
  3. Ignore the required immunizations: Make sure all recommended and required immunizations, particularly the tetanus shot within the last 10 years, are up to date. Skipping this step could result in non-participation.
  4. Overlook restrictions: If there are specific activity restrictions due to health concerns, make sure they are clearly noted in the form. This ensures the safety and well-being of the participant throughout the event.

By following these guidelines, participants and their guardians can ensure that the BSA 680-001 form is accurately and thoroughly completed, promoting a safe and enjoyable scouting experience.

Misconceptions

Understanding the complexities of documentation required for various activities can sometimes be challenging, especially when it involves health and safety measures. The BSA 680-001 form, crucial for participation in high-adventure scouting activities, is often surrounded by misconceptions. Clearing up these misunderstandings can foster a safer, more inclusive, and well-prepared scouting experience for all participants. Here are four common misconceptions about the BSA 680-001 form:

  • Misconception 1: The Form is Only for High-Adventure Bases

    While Part C of the form is indeed focused on high-adventure participants, the BSA 680-001 form encompasses more than just high-adventure activities. It includes sections on informed consent, release agreements, and health history (Parts A and B) that are relevant for all scouting events, ensuring that all participants are medically and legally prepared for the activities ahead. This broad applicability ensures a consistent approach to health and safety for all scouts, not just those engaging in high-adventure programs.

  • Misconception 2: Personal Health and Insurance Information Is Optional

    Some might think they can leave sections regarding health insurance information or the detailed health history vague or unanswered. However, providing comprehensive health and insurance information is crucial. It ensures that scouts receive proper care in case of an emergency, and it helps leaders and medical providers make informed decisions about each participant's capability to safely engage in activities.

  • Misconception 3: Informed Consent Is Only Relevant for New Scouts

    Even those who have previously participated in scouting activities might believe they do not need to sign the informed consent section each year. Nonetheless, this section is vital for all participants, regardless of their experience level. Informed consent must be renewed annually because it confirms that participants and guardians are aware of and accept the potential risks involved in the scouting activities.

  • Misconception 4: Medication Details Are Only Required If You're Taking Prescription Drugs

    There's often a belief that the medication section of the form needs to be filled out only by those who are taking prescription medications. However, it's important to list all medications, including over-the-counter drugs, that a participant might be using. This comprehensive approach helps ensure the safety and well-being of scouts by providing adult leaders and medical staff with a full picture of a participant's health needs.

Addressing these misconceptions fosters a safer environment by ensuring all participants and their guardians fully understand the importance of each section of the BSA 680-001 form. Through complete and accurate information, scouts can enjoy a fulfilling and enriching experience with the peace of mind that comes from being well-prepared and informed.

Key takeaways

Filling out the BSA 680-001 form is a comprehensive process that involves providing detailed personal, health, and insurance information for participants in Scouting activities, especially those planning to attend high-adventure bases. Here are five key takeaways about completing and using this form effectively:

  • Accurate and Complete Health Information is Crucial: Part B of the form requires a thorough medical history and current health status, including allergies, medications, immunizations, and any past surgeries or hospitalizations. This information helps ensure the safety of participants by allowing activity coordinators to make informed decisions about each participant's ability to safely engage in activities.
  • Informed Consent and Understanding of Risks: Part A emphasizes the necessity for participants (or their guardians) to give informed consent, acknowledging the inherent risks involved in the Scouting activities and granting permission for emergency medical treatment. It is a reminder of the physical, mental, and emotional challenges these activities may present and the importance of understanding these challenges before participating.
  • Emergency Contacts and Authorization: The form requires the designation of emergency contact persons, including those authorized or not authorized to take participants to and from events. This information is vital for ensuring participants' safety and streamlining communication in case of an emergency.
  • Required Immunizations and Health Exemptions: Immunizations, especially against tetanus, are required for participants, with the form stipulating the need for an up-to-date tetanus shot within the last ten years. However, provisions are made for those who, for religious, philosophical, or political reasons, cannot meet the immunization requirements, indicating the need for an Immunization Exemption Request form.
  • High-Adventure Program Specifics: Those attending high-adventure bases must meet additional requirements related to their health and physical fitness, as detailed in Part C and the high-adventure risk advisory sections. These include weight restrictions, controlled medical conditions (such as asthma, diabetes, or hypertension), and the necessity for certain medications and devices (like EpiPens and inhalers). This information ensures that participants can safely undertake the physical demands of these programs.

Understanding these key points before filling out the BSA 680-001 form can significantly enhance the safety and preparedness of participants engaging in Scouting activities.

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