The Ute District Troops and Teams are proud to sponsor the
Emergency Preparedness & C.E.R.T. Spring Camporee
25 – 27 April 2014 Camp Falcon, Fort Carson, CO
BLANK FORM PACKET
At Check-In Troop/Crew Leaders MUST have the following ready for inspection/turn-in:
☐ Registration Worksheet COPY TURNED IN at Check-in (see enclosed form)
☐ Payment Receipt COPY TURNED IN at Check-in (recommend it be stapled to Registration
Worksheet)
☐ Unit Roster COPY TURNED IN at Check-in (see enclosed form)
☐ Tour Plan – submitted / filed online in accordance with Pikes Peak Council policy - A COPY of
the Tour Plan is TURNED IN at Check-in. Troops will not be permitted to stay at the Ute
Spring Camporee without a Tour Plan. No exceptions.
☐ Covenant Not to Sue (Hold Harmless) must be filled out for each participant and TURNED
IN at Check-in (see enclosed form). **Enclosed form is specific for this event**
☐ OA Election Sheet COPY TURNED IN at Check-in (recommend it be stapled to OA Call
Out List)
☐ OA Call Out List – (name of Scouts / Adults to be Called Out at Campfire) (see enclosed
form) TURNED IN at Check-in
☐ Signed Permission Slip for each Scout. Troop Permission Slips must be brought to the
Camporee and be available for inspection at Check-in, but will be kept in the Leaders’ care.
☐ Medical Forms- Medical Forms must be brought to the Camporee and be available for
inspection at Check-in, but will be kept in the Leaders’ care, in case of emergency.
REGISTRATION WORKSHEET UTE Spring Camporee
25 – 27 April 2014
Camp Falcon, Fort Carson, CO
Registration is 14 February thru 11 April 2014 at a fee of $12.00 per person. A late fee of $3.00 is
assessed between 12 – 18 April ($15.00 per person). There will be no registrations accepted after midnight (MDT) Friday, 18 April 2014. There will be no exceptions to this policy. NOTE: Cancellation Policy - If a Scout/Scouter cancellation occurs AFTER Friday, 18 April 2014 (the last
date for registration) payment date, NO fees will be refunded unless documented by a medical doctor or a
death occurred in the family.
Troops / Crews
Troop/ Crew #: _________ Scoutmaster \ Crew Leader Name: _____________________
Phone Number: _______-_______-_______ Email _____________________@_________
Point of Contact attending the Camporee (if different from above): ___________________
Phone: ______-_______-_______
Scout Registration Fee $12.00 ($15.00 Late Fee Applied)
Number of Scouts __________ X $12.00 or $15.00 _____________
Number of Adult Leaders __________ X $12.00 or $15.00 ______________
Total Due = $ _____________
Staple Payment Receipt Here:
Unit Roster UTE Spring Camporee
25 - 27 APRIL 2014
Troop / Crew # ___________
Patrol Name _________________
1)____________________ Patrol Leader
2)_______________________________
3)_______________________________
4)_______________________________
5)_______________________________
6)_______________________________
7)_______________________________
8)_______________________________
9)_______________________________
10)______________________________
Patrol Name _________________
1)____________________ Patrol Leader
2)_______________________________
3)_______________________________
4)_______________________________
5)_______________________________
6)_______________________________
7)_______________________________
8)_______________________________
9)_______________________________
10)______________________________
Patrol Name _________________
1)____________________ Patrol Leader
2)_______________________________
3)_______________________________
4)_______________________________
5)_______________________________
6)_______________________________
7)_______________________________
8)_______________________________
9)_______________________________
10)______________________________
Patrol Name _________________
1)____________________ Patrol Leader
2)_______________________________
3)_______________________________
4)_______________________________
5)_______________________________
6)_______________________________
7)_______________________________
8)_______________________________
9)_______________________________
10)______________________________
New Scout Roster 1)_______________________________
2)_______________________________
3)_______________________________
4)_______________________________
5)_______________________________
6)_______________________________
7)_______________________________
8)_______________________________
9)_______________________________
10)_______________________________
1
TOUR AND ACTIVITY PLANDate __________________________________________________________________________
Pack Troop/team Crew/Ship Contingent unit/crew Unit No. _________ Chartered organization __________________________________________
Council name/No. ________________________________________________/_______________
District _________________________________________________________________________
Description of tour or activity ______________________________________________________
From (city and state) ______________________________to _____________________________
Dates _________________________ to ________________________ Total days ____________
Itinerary: It is required that the following information be provided for each day of the tour. (Note: Speed or excessive daily mileage increases the possibility of accidents.) Attach an addi-tional page if more space is required. Include detailed information on campsites, routes, and �oat plans, and include maps for wilderness travel as required by the local council.
DateTravel
Mileage Overnight stopping place (Check if reservations are cleared.)From To
Type of trip: Day trip Short-term camp (less than 72 hours) Other (OA Weekend, etc.) _________________________________
Long-term camp (longer than 72 hours) High-adventure activities High-adventure base____________________
Party will consist of (number):____ Youth—male ____ Youth—female____ Adults—male ____ Adults—female
Party will travel by (check all that apply): Car Bus Train Plane Van Boat Other ______________________________________________________________
Leadership and Youth Protection Training: Boy Scouts of America policy requires at least two adult leaders on all BSA activities. Coed Venturing crews must have both male and female leaders older than 21 for overnight activities. All registered adults must have completed BSA Youth Protection training. At least one registered adult who has completed BSA Youth Protection training must be present at all events and activities. Youth Protection training is valid for two years from the date completed.
Adult leader responsible for this group (must be at least 21 years old):
Name ____________________________________ Age _______ Scouting position _________________________________________________
Address __________________________________________________________________________________ Member No. ________________
City __________________________________________________________ State _______________ Zip code ___________________________
Phone _______________________________ Email ___________________________________ Youth Protection training date ______________
Assistant adult leader name(s) (minimum age 18, or 21 for Venturing crews):
Name ____________________________________ Age _______ Scouting position _________________________________________________
Address __________________________________________________________________________________ Member No. ________________
City __________________________________________________________ State _______________ Zip code ___________________________
Phone _______________________________ Email ___________________________________ Youth Protection training date ______________
Attach a list with additional names and information as outlined above.
Our travel equipment will include a �rst-aid kit and a roadside emergency kit.
The group will have in possession an Annual Health and Medical Record for every participant.
We certify that appropriate planning has been conducted using the Sweet 16 of BSA Safety, quali�ed and trained supervision is in place, permissions are secured, health records have been reviewed, and adult leaders have read and are in possession of a current copy of Guide to Safe Scouting and other appropriate resources. Any items needing attention will be resolved before the tour or activity date.
Signature: Committee chair or chartered organization representative Signature: Adult leader
Unit single point of contact (not on tour)
Name ____________________________________Phone __________________Email_________________________________________________
For o�ce use
Tour and activity plan No. ____________
Date received _______________________
Date reviewed ______________________
Council stamp/signatures
2
Tour involves: Swimming Boating Climbing Orienta hts (attach Flying Plan required) Wilderness or backcountry (must carry Wilderness Use Policy and follow principles of Leave No Trace) Shooting Other (specify)
Activity Standards: Where swimming or boating is included in the program, Safe Swim Defense and/or Safety A oat are to be followed. If climbing/rappelling is included, then Climb On Safely must be followed. At least one person must be current in CPR/AED from any recognized agency to meet Safety A at and Climb On Safely guidelines. At least one adult on a pack overnighter must have completed Basic Adult Leader Outdoor Orientation (BALOO). At least one adult must have completed Planning and Preparing for Hazardous Weather training for all tours and activities. Trek Safely and Basic First Aid are recommended for all tours, and Wilderness First Aid is recommended for all backcountry tours.
Expiration date of commitment card/training (two years from completion date)
Name Age Youth Protection
Planning and Preparing
for Hazardous Weather
BALOO(no
expiration)
Climb On Safely Safe Swim Defense
Safety A at
Name Age CPR Cer ation/Agency CPR Expiration Date
First-Aid Cer ation/Agency First Aid Expiration Date
Name Age NRA Instructor and/or RSO
No. _______ R Shotgun Pistol (Venturing only) Range Safety O cer Muzzle-loading r Muzzle-loading shotgun
No. _______ R Shotgun Pistol (Venturing only) Range Safety O cer Muzzle-loading r Muzzle-loading shotgun
Unauthorized and Restricted Activities: The BSA’s general liability insurance policy provides coverage for bodily injury or property damage that arises out of an o cial Scouting activity as d ned by the Guide to Safe Scouting. Volunteers, units, chartered organizations, and local councils that engage in unauthorized activities are jeopardizing their insurance coverage. PLEASE DO NOT PUT YOURSELF AT RISK.INSURANCEAll vehicles MUST be covered by a liability and property damage insurance policy. The amount of this coverage must meet or exceed the insurance requirement of the state in which the vehicle is licensed and comply with or exceed the requirements of the country of destination for travel outside the United States. It is recommended, however, that coverage limits are a $100,000 combined single limit. Any vehicle designed to carry 10 or more passengers is required to have a $500,000 combined single limit. In the case of rented vehicles, the requirement of coverage limits can be met by combining the limits of personal coverage carried by the driver with coverage carried by the owner of the rented vehicle.
If the vehicle to be used is designed to carry more than 15 people (including the driver), the driver must have a valid commercial driver’s license (CDL). In some states (California, for example), this policy applies to drivers of vehicles designed to carry 10 or more people.
All vehicles used in travel outside the United States must carry a public liability and property damage liability insurance policy that complies with or exceeds the requirements of that country. Attach an additional page if more space is required.
Name ___________________________________________________________ CDL expires ___________________________________________
Name ___________________________________________________________ CDL expires ___________________________________________
680-014 2011 Printing Rev. 12/2011
MAKE MODEL YEAR
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DRIVER/OWNER
VALID DRIVER’SLICENSE(Y or N)
LIABILITY INSURANCE COVERAGE
Combined Single Limit
Guide to Tour Planning Principles
Covenant Not to Sue
Pikes Peak Council Boy Scouts of America
Youth Section (for participants who are younger than 18) I, ______________________________________, do hereby certify that I am the legal parent / guardian (Parent/Guardian’s Full Name)
of_____________________________________, who is voluntarily participating with Troop _______, BSA, Participant’s Full Name #
BSA, Pikes Peak Council, Ute District Troops and Crews 2014 Spring Camporee, El Paso County Sheriff’s Office,
Emergency Preparedness & Community Emergency Response Team (CERT) at Camp Falcon, Fort Carson, CO.
Adult Section: (for participants who are 18 years of age or older)
I, _____________________________________, am voluntarily participating with Troop _________, at the Participant’s Full Name #
BSA, Pikes Peak Council, Ute Troops and Crews 2014 Spring Camporee, El Paso County Sheriff’s Office, Emergency
Preparedness & Community Emergency Response Team (CERT) at Camp Falcon, Fort Carson, CO.
RELEASE, COVENANT & HOLD HARMLESS AGREEMENT KNOW ALL MEN BY THESE PRESENTS that in
exchange for the permission of Camp Falcon to use its properties do herewith release Camp Falcon from liability
for any and all injuries which my son may sustain during the period of time that he is upon and using its property,
whether any such injuries may be from negligence of breach of warranty of Camp Falcon or any other party or
person who may cause him injury. This prospective release is effective as to Camp Falcon any agent, employee, or
other person for whose conduct Camp Falcon may be liable. This Release is a release of any and all claims, demands,
damages, actions, causes of action, or suits at law or in equity of whatsoever kind or nature, for or because of any
matter or thing done, omitted, or suffered to be done by Camp Falcon prior to and during the period of time my son
is using its property. I understand that I may come in contact with latex material utilized for the moulage of
exercise victims, and that I will come in contact with soybean based “fogger” mist utilized in the Search and
Rescue class. I agree to hold El Paso County, the El Paso County Sheriff’s Office, and the El Paso County Office of
Emergency Management and their agents and personnel, harmless from any and all claims, actions, suits, and/or
injury that I may suffer and which may arise as a result of my participation in the above-mentioned exercise. I
agree to follow the rules established by the instructors, safety officers, and exercise controllers, and to exercise
reasonable care while participating in the classes and exercise. I understand that if I fail to follow any instructions
issued by these personnel, or if I fail to exercise reasonable care, I can be administratively removed from the
classes and exercise.
In addition to the above described Release, I herewith and hereby covenant not to cause any litigation to be filed
against Camp Falcon or El Paso County Sheriff’s Office personnel and to hold them harmless and indemnify each for
any litigation which is filed against it, or claims made against it which litigation or claims are based on my conduct.
FURTHER, Releasor sayeth naught.
Dated this _______day of ________ 2014 (Date) (Month)
SIGNATURE (Parent/Guardian) ___________________________ Name (please print) __________________
Address _________________________________ City__________________________, State__________,
ZIP Code___________, USA
Home Phone ____________Work Phone _________________
Colorado State Law Requires that all information must be complete and legible before users may enter the field.
Required for Each Participant
OA CALL OUT FORM
UTE Spring Camporee
25 – 27 APRIL 2014
(with copy of OA Election Sheet stapled to it)
Troop #____________
Scouts
1)_______________________________
2)_______________________________
3)_______________________________
4)_______________________________
5)_______________________________
6)_______________________________
7)_______________________________
8)_______________________________
Adult Leaders
1)_______________________________
2)_______________________________
3)_______________________________
This form is recommended for unit use to obtain approval and consent for Tiger Cubs, Cub Scouts, Webelos Scouts, Boy Scouts, Varsity Scouts, Venturers, and guests (if applicable) under 21 years of age to participate in a den, pack, team, troop, or crew trip, expedition, or activity. This form is required for use with flying plans and should be attached to the flying plan application. It is recommended that parents keep a copy of the form and contact the tour leader in the event of any questions or in case emergency contact is needed. Additional copies of this form along with the Guide to Safe Scouting are available for download from Scouting Safely at www.scouting.org/forms.
Se recomienda que la unidad use este formulario para obtener la aprobación y consentimiento para los Tiger Cubs, Cub Scouts, Webelos Scouts, Boy Scouts, Varsity Scouts, Venturers e invitados (si es que aplica) menores de 21 años que participen en un viaje, expedición o actividad del den, pack, equipo, tropa o grupo. Este formulario es obligatorio junto con los permisos de vuelo y deben adjuntarse a la solicitud de permiso de vuelo. Se recomienda que los padres de familia guarden una copia del formulario y se pongan en contacto con el líder de la excursión si es que tienen alguna pregunta o en caso de que se necesite un contacto de emergencia. Las copias adicionales de este formulario junto con la Guía para un Scouting seguro se encuentran disponibles para descargar desde Scouting Safely en www.scouting.org/forms.
ACTIVITY CONSENT FORM AND APPROVAL BY PARENTS OR LEGAL GUARDIANFORMULARIO DE CONSENTIMIENTO Y APROBACIÓN DE ACTIVIDAD POR PARTE
DE LOS PADRES DE FAMILIA O TUTORES
HOLD HARMLESS AGREEMENTI understand that participation in Scouting activities involves a certain degree of risk and can be physically, mentally, and emotionally demanding. I have carefully considered the risk involved and have given consent for myself or my child to participate in this activity. I also understand that participation in this activity is entirely voluntary and requires participants to abide by applicable rules and standards of conduct. I release the Boy Scouts of America, the local council, the activity coordinators, and all employees, volunteers, related parties, or other organizations associated with the activity from any and all claims or liability arising out of this participation.
In case of emergency involving my child, I understand every effort will be made to contact me. In the event I cannot be reached, I hereby give my permission to the medical provider selected by the adult leader in charge to secure proper treatment, including hospitalization, anesthesia, surgery, or injections of medication for my child. Medical providers are authorized to disclose to the adult in charge 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.
ACUERDO DE INDEMNIZACIÓN Y EXONERACIÓN DE RESPONSABILIDADEntiendo que la participación en actividades Scouting implica un cierto grado de riesgo y que pueden ser física, mental y emocionalmente agotadoras. He considerado cuidadosamente el riesgo involucrado y doy mi consentimiento para mi mismo o mi hijo para participar en la actividad. Entiendo que la participación en la actividad es completamente voluntaria y requiere que los participantes se acaten a las reglas y estándares de conducta pertinentes. Libero a Boy Scouts of America, al concilio local, a los coordinadores de la actividad y a todos los empleados, voluntarios, partes relacionadas u otras organizaciones asociadas con la actividad de cualquiera y todas las demandas o responsabilidades que surjan de esta participación.
En caso de una emergencia que tenga que ver con mi hijo, sé que se harán todos los esfuerzos necesarios para contactarme. En caso de que no me contacten, autorizo al proveedor médico seleccionado por el líder adulto encargado, de asegurarse de que se le ofrezca a mi hijo el tratamiento adecuado, incluyendo hospitalización, anestesia, cirugía o inyecciones de medicamento. Los proveedores médicos están autorizados para informar al adulto encargado los hallazgos de la exploración física, los resultados de pruebas y el tratamiento otorgado con el propósito de una evaluación médica del participante, seguimiento y comunicación con los padres o tutores del participante y/o la determinación de la capacidad del participante para continuar en las actividades del programa.
______________________________________________________ _____ _____________________________________________________ Birth date (month/day/year) ____/____/____ Age during activity ________ First name of participant Middle initial Last name Fecha de nacimiento (día/mes/año) Edad al momento de realizar Nombre del participante Inicial del sugundo nombre Apellido la actividad
____________________________________________________________________________________________________________________________________________________________________________________ Address Domicilio
City ____________________________________________________________________________________ State __________________________________________________________ Zip _____________________Ciudad Estado Código postal
Has approval to participate in (Name of activity, orientation flight, outing trip, etc.) __________________________________________________________________________________________________________________Tiene la aprobación para participar en (Nombre de la actividad, vuelo de orientación, excursión, etc.)
From ______________ to ______________ Without restrictions Special considerations or restrictions:De (Date) a (Date) Sin restricciones Consideraciones o restricciones especiales: (fecha) (fecha)
______________________________________________________________________________________________________________________________________________________ ________________________ Participant’s signature Date Firma del participante Fecha
______________________________________________________ __________________________________________________________________________________________
__________________________________________________________________________________________
________________________ Parent/guardian printed name Parent/guardian signature Date Nombre con letra de molde del padre de familia/tutor Firma del padre de familia/tutor Fecha
______________________________________________________ ______________________________________________________________________________________________________________________ Area code and telephone number (best contact and emergency contact) Email (for use in sharing more details about the trip or activity) Código de área y número telefónico (primer contacto y contacto de emergencia) Correo electrónico (para más detalles sobre el viaje o actividad)
Contact the adult tour leader with any questions: Póngase en contacto con el líder adulto de la excursión si es que tiene preguntas:
Name ___________________________________________________________________ Phone ___________________________ Email ________________________________________________________________Nombre Teléfono Correo electrónico
680-673 2012 Printing
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Annual Health and Medical Record Registro Médico y de Salud AnualPart A/Parte A GENERAL INFORMATION/INFORMACIÓN GENERAL
Name ___________________________________________________ Date of birth __________________________________ Age ___________ Male Female Nombre Fecha de nacimiento (MM/DD/Year) - (MM/DD/Año) Edad Masculino Femenino
Address _____________________________________________________________________________________________ Grade completed (youth only) _____________________Domicilio Grado escolar completado (sólo niños)
City _________________________________________________________ State _____________ Zip _____________________ Phone No. ______________________________Ciudad Estado Código postal No. telefónico
Unit leader ___________________________________________________ Council name/No. __________________________________________ Unit No. __________________Líder de la unidad Nombre y no. del concilio No. de unidad
Social Security No. (optional; may be required by medical facilities for treatment) __________________________________ Religious preference _______________________No. de Seguro Social (opcional; puede ser solicitado por las instalaciones médicas para brindar tratamiento) Preferencia religiosa
Health/accident insurance company ___________________________________________________________ Policy No. _______________________________________________Compañía de seguro médico/accidental No. de póliza
ATTACH A PHOTOCOPY OF BOTH SIDES OF INSURANCE CARD. IF YOU DO NOT HAVE MEDICAL INSURANCE, ENTER “NONE” ABOVE. ANEXAR UNA FOTOCOPIA DE AMBOS LADOS DE LA TARJETA DEL SEGURO. SI USTED NO TIENE SEGURO MÉDICO, ESCRIBA “NINGUNO.”
In case of emergency, notify/En caso de emergencia, notificar a:Name ________________________________________________________________________________ Relationship ___________________________________________________Nombre Parentesco
Address ______________________________________________________________________________________________________________________________________________Domicilio
Home phone ________________________________________ Business phone ____________________________________ Mobile phone ______________________________Teléfono de casa Teléfono de oficina Teléfono móvil
Alternate contact name ____________________________________________________________________ Alternate’s phone __________________________________________Nombre de contacto alterno Teléfono del contacto alterno
HEALTH HISTORY/HISTORIAL MÉDICO Please fill in the bubbles as indicated below:Do you currently have, or have you ever been treated for any of the following? Por favor rellene los círculos tal como se indica a continuación:
¿Tiene actualmente, o ha tenido alguna vez los siguientes? Incorrect: Correct: Incorrecto Correcto
Yes/Sí No/No Condition/Padecimiento Explain/Explique
Asthma Last attack: (MM/YY) Asma Último ataque: (MM/AA)
Diabetes Last HbA1c: (Percentage) Diabetes Última HbA1c: (Porcentaje)
Hypertension (high blood pressure) Hipertensión (presión alta)
Heart disease/heart attack/chest pain/heart murmur Enfermedad del corazón/infarto/dolores de pecho/soplo cardíaco
Stroke/TIA Apoplejía/Accidente isquémico transitorio
Lung/respiratory disease Enfermedades pulmonares/respiratorias
Ear/sinus problems Problemas del oído/senos paranasales
Muscular/skeletal condition Condiciones musculares/óseas
Menstrual problems (women only) Problemas menstruales (sólo mujeres)
Psychiatric/psychological and emotional difficulties Dificultades psiquiátricas/psicológicas y emocionales
Behavioral/neurological disorders Trastornos de conducta/neurológicos
Bleeding disorders Enfermedades hemorrágicas
Fainting spells Desmayos
Thyroid disease Enfermedades de la tiroides
Kidney disease Enfermedades del riñón
Sickle cell disease Anemia falciforme
Seizures Last seizure: (MM/YY)Convulsiones Última convulsión: (MM/AA)
Sleep disorders (e.g., sleep apnea) Trastornos del sueño (por ejemplo, síndrome de apnea-hipopnea durante el sueño)
Use CPAP: Yes No Usa CPAP Sí No
Abdominal/digestive problems Problemas abdominales/digestivos
Surgery Last surgery: (MM/YY) Cirugía Última cirugía: (MM/AA)
Serious injury Lesión grave
Excessive fatigue or shortness of breath with exercise Fatiga en exceso o dificultad para respirar al hacer ejercicio
Other Otro
High-adventure base participants:Participantes en la base de aventura extrema:Expedition/crew No. Expedición/grupo no.: ______________________________or staff position o puesto fijo: _____________________________________
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PART A (continued on next page)Page 1 of 2
MEDICATIONS List all medications currently used. (If additional space is needed, please photocopy this part of the health form.) Inhalers and EpiPen information must be included, even if they are for occasional or emergency use only.
MEDICAMENTOS Enumere todos los medicamentos que usa en la actualidad. (Si requiere espacio adicional, favor de sacar una fotocopia de esta parte del formulario.) Se debe incluir información sobre inhaladores y EpiPen, incluso si son sólo para uso ocasional o en caso de emergencia.
Administration of the above medications is approved by (if required by your state): _________________________________________________________/ _______________________________________________________La administración de los medicamentos arriba Parent/guardian signature and/or MD/DO, NP, or PA signaturemencionados está aprobada por (si lo requiere su estado) Firma del padre o tutor y/o Firma del Dr., Enfermera profesional, Asistente médico
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.
Asegurarse de traer los medicamentos en cantidades suficientes y en los envases originales. Asegurarse de que NO ESTÉN CADUCADOS, incluyendo inhaladores y EpiPens. NO DEBE DEJAR DE tomar cualquier medicamento de mantenimiento a menos que se lo indique su médico.
No medications Sin medicamentos
Additional medications (sheet attached) Medicamentos adicionales (hoja anexa)
680-001 2012 Printing
Rev. 9/2012
HEALTH HISTORY/HISTORIAL MÉDICO
Please fill in the bubbles as indicated: Por favor rellene los círculos tal como se indica:
Incorrect:
Correct: Incorrecto Correcto
Page 2 of 2
Yes/Sí No/No Allergies or Reaction to Alergias o Reacciones a
Explain Explique
Medication Medicamentos
Food, plants, or insect bites Alimentos, plantas o picaduras de insectos
The following immunizations are recommended by the BSA. Tetanus immunization is required and must have been received within the last 10 years. For each item, indicate if you have been immunized, the date of the immunization (MM/YY), if you have had the disease, and the date (MM/YY).
BSA recomienda las siguientes vacunas. La vacuna contra el Tétanos es obligatoria y debe haberla recibido en los últimos 10 años. Por cada punto, indique si ha sido vacunado, la fecha en que la recibió (MM/AA), si ha padecido la enfermedad, y la fecha (MM/AA).
Immunized? ¿Vacunado? Immunizations
VacunasDate (MM/YY) Fecha (MM/AA)
Had Disease?¿La ha padecido? Date (MM/YY)
Fecha (MM/AA)Yes/Sí No/No Yes/Sí No/No
Tetanus Tétano
Pertussis Tos ferina
Diphtheria Difteria
Measles Sarampión
Mumps Paperas
Rubella Rubéola
Polio Polio
Chicken pox Varicela
Hepatitis A Hepatitis A
Hepatitis B Hepatitis B
Meningitis Meningitis
Influenza Influenza
Other (i.e., HIB) Otra (por ejemplo, HIB)
Exemption to immunizations claimed (form required). Exención de vacunas solicitada (formulario obligatorio).
Medication Medicamento _________________________________________
Strength Frequency Dosis ____________________ Frecuencia ________________
Approximate date started Fecha aproximada de inicio _____________________________
Reason for medication Razón del medicamento ________________________________
______________________________________________________
Medication Medicamento _________________________________________
Strength Frequency Dosis ____________________ Frecuencia ________________
Approximate date started Fecha aproximada de inicio _____________________________
Reason for medication Razón del medicamento ________________________________
______________________________________________________
Medication Medicamento _________________________________________
Strength Frequency Dosis ____________________ Frecuencia ________________
Approximate date started Fecha aproximada de inicio _____________________________
Reason for medication Razón del medicamento ________________________________
______________________________________________________
Medication Medicamento _________________________________________
Strength Frequency Dosis ____________________ Frecuencia ________________
Approximate date started Fecha aproximada de inicio _____________________________
Reason for medication Razón del medicamento ________________________________
______________________________________________________
Medication Medicamento _________________________________________
Strength Frequency Dosis ____________________ Frecuencia ________________
Approximate date started Fecha aproximada de inicio _____________________________
Reason for medication Razón del medicamento ________________________________
______________________________________________________
Medication Medicamento _________________________________________
Strength Frequency Dosis ____________________ Frecuencia ________________
Approximate date started Fecha aproximada de inicio _____________________________
Reason for medication Razón del medicamento ________________________________
______________________________________________________
Are you allergic to or do you have any adverse reaction to any of the following?¿Es alérgico a, o le causa alguna reacción adversa cualquiera de los siguientes?
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High-adventure base participants: Participantes en la base de aventura extrema:Expedition/crew No./Expedición/grupo no.: ______________________________or staff position/o puesto fijo: ___________________________________________Part B/Parte B
Informed Consent and release agreementI understand that participation in Scouting activities involves a certain degree of risk and can be physically, mentally, and emotionally demanding. I also understand that participation in these activities is entirely voluntary and requires participants to abide by applicable rules and standards of conduct.
In case of an emergency involving me or my child, I understand that every effort will be made to contact the individual listed as the emergency contact person. In the event that this person cannot be reached, permission is hereby given to the medical provider selected by the adult leader in charge to secure proper treatment, including hospitalization, anesthesia, surgery, or injections of medication for me or my child. Medical providers are authorized to disclose 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.
I have carefully considered the risk involved and give consent for myself and/or my child to participate in these activities. I approve the sharing of the information on this form with BSA volunteers and professionals who need to know of medical situations that might require special consideration for the safe conducting of Scouting activities.
I release the Boy Scouts of America, the local council, the activity coordinators, and all employees, volunteers, related parties, or other organizations associated with the activity from any and all claims or liability arising out of this participation.
I hereby assign and grant to the local council and the Boy Scouts of America 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 hereby 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 Boy Scouts of America, and I specifically waive any right to any compensation I may have for any of the foregoing.
notIfICaCIÓn de ConsentImIento Y eXoneraCIÓn de resPonsaBIlIdadEntiendo que la participación en actividades Scouting implica un cierto grado de riesgo y que pueden ser física, mental y emocionalmente agotadoras. Asimismo, entiendo que la participación en dichas actividades es completamente voluntaria y requiere que los participantes se acaten a las reglas y estándares de conducta pertinentes.
En caso de que yo, o mi hijo, nos veamos involucrados en un caso de emergencia, entiendo que se hará todo lo posible para contactar al individuo mencionado como persona a contactar en caso de emergencia. En caso de que dicha persona no pueda ser localizada, por este medio otorgo permiso al proveedor de servicios médicos seleccionado por el líder adulto a cargo para asegurar que se proporcione el tratamiento adecuado, incluyendo hospitalización, anestesia, cirugía o inyecciones de medicamentos para mí o mi hijo. Los proveedores médicos están autorizados a compartir información médica protegida con el adulto a cargo, el personal médico del campamento, la administración del campamento, o cualquier médico o proveedor de servicios médicos involucrado en la administración de atención médica al participante. La Información médica protegida/Información médica confidencial (PHI/CHI, por sus siglas en inglés) bajo los Estándares de privacidad de información médica individualmente identificable, 45 C.F.R. §§160.103, 164.501, etc., y siguientes como se enmiendan de vez en cuando, incluye resultados de reconocimientos médicos, resultados de pruebas y tratamiento proporcionado para propósitos de evaluación médica del participante, seguimiento y comunicación con los padres o tutor del participante, y determinación de la habilidad del participante de continuar con las actividades del programa.
He considerado cuidadosamente el riesgo implicado y he dado el consentimiento para mí mismo o mi hijo de participar en dichas actividades. Apruebo que se comparta la información contenida en este formulario con los voluntarios y profesionales de BSA que necesiten tener conocimiento de condiciones médicas que puedan requerir consideración especial para la realización de actividades Scouting de manera segura.
Eximo a Boy Scouts of America, al concilio local, a los coordinadores de la actividad y a todos los empleados, voluntarios, grupos involucrados u otras organizaciones asociadas con la actividad, de cualquier y toda reclamación o responsabilidad que surja a raíz de esta participación.
Por este conducto asigno y otorgo al concilio local y a Boy Scouts of America el derecho y permiso para usar y publicar las fotografías/películas/videocintas/representaciones electrónicas y grabaciones de sonido de mí o mi hijo realizadas en todas las actividades Scouting, y por este medio exonero a Boy Scouts of America, al concilio local, a los coordinadores de la actividad y a todos los empleados, voluntarios, grupos involucrados u otras organizaciones asociadas con la actividad, de cualquier y toda responsabilidad por dicho uso y publicación.
Por este conducto autorizo la reproducción, venta, derechos reservados, exhibición, transmisión, almacenamiento electrónico y distribución de dichas fotografías/películas/ videocintas/representaciones electrónicas y grabaciones de sonido sin limitación a discreción de Boy Scouts of America, y específicamente renuncio a cualquier derecho de compensación alguna que pueda tener por cualquiera de lo anterior.
Without restrictions./Sin restricciones.
With special considerations or restrictions (list)/Con condiciones especiales o restricciones (lista):
________________________________________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________________________________
Yes/Sí
No/No
PART B (continued on next page)Page 1 of 2
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680-001 2012 Printing
Rev. 9/2012
Page 2 of 2
ADULTS AUTHORIZED TO TAKE YOUTH TO AND FROM EVENTS: You must designate at least one adult. Please include a telephone number.
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, Philmont Training Center, Northern Tier, Florida Sea Base, or the Summit Bechtel Reserve: I have also read and understand the risk advisories explained in Part D, 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.
ADULTOS AUTORIZADOS PARA TRANSPORTAR AL NIÑO HACIA Y DESDE LOS EVENTOS:Debe designar por lo menos a un adulto. Por favor incluya un número telefónico.
Entiendo que, si cualquier información que he/hemos proporcionado es errónea, puede limitar o eliminar la oportunidad de participación en cualquier evento o actividad.
Si participo en Philmont, el Centro de Capacitación Philmont, Northern Tier, la Base Marina de la Florida o Summit Bechtel Reserve: También he leído y entiendo las advertencias de riesgo explicadas en la Parte D, incluyendo los requisitos y restricciones de estatura y peso, y entiendo que al participante no se le permitirá intervenir en programas de aventura extrema si dichos requisitos no se cumplen. El participante tiene permiso de intervenir en todas las actividades de aventura extrema descritas, excepto aquellas específicamente señaladas por mí o el proveedor de servicios médicos. Si el participante es menor de 18 años, se requiere la firma de el padre/madre o tutor.
1. Name/Nombre __________________________________________________________________________Telephone/Teléfono ________________________
2. Name/Nombre __________________________________________________________________________Telephone/Teléfono ________________________
3. Name/Nombre __________________________________________________________________________Telephone/Teléfono ________________________
Adults NOT authorized to take youth to and from events/Adultos NO autorizados para transportar al niño hacia y desde los eventos:
1. Name/Nombre __________________________________________________________________________Telephone/Teléfono ________________________
2. Name/Nombre __________________________________________________________________________Telephone/Teléfono ________________________
3. Name/Nombre __________________________________________________________________________Telephone/Teléfono ________________________
Participant’s name/Nombre del participante _____________________________________________________________________________________________
Participant’s signature/Firma del participante Date/Fecha
Parent/guardian’s signature/Firma del padre o tutor Date/Fecha (if participant is under the age of 18/si el participante es menor de 18 años)
Second parent/guardian signature/Firma del otro padre o tutor Date/Fecha (if required; for example, CA/si se requiere; por ejemplo en CA)
This Annual Health and Medical Record is valid for 12 calendar months. Este Registro Médico y de Salud Anual tiene vigencia por 12 meses calendario.
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