Order Of The Arrow - Boy Scouts Of America Health And Medical Record Form Page 5
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5Authorization for Participation and Medical Care:
I the undersigned have read and understand this entire form, including the sections
entitled “Information for the Examiner and the Applicant”. The applicant’s health history is accurate and complete to the best of my knowledge and
the applicant has permission to engage in all ArrowCorps
activities described, except as specifically noted on this form by me or the physician. If
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I cannot be reached in an emergency, I hereby give permission for medical personnel, and/or the adult leader in charge, to treat, hospitalize,
secure anesthesia, and/or to order injection, surgery or other treatment for the person described herein. I further authorize the ArrowCorps
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medical staff to disclose to, or obtain from, any physician, hospital, or other health care provider, any information reasonably deemed necessary
for the applicant’s medical treatment.
I hereby authorize the physicians and their associates of the ArrowCorps
program to perform such diagnostic, medical, and/or surgical treatment
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on my son or myself as may be deemed medically necessary in order to assure the safety of my son or myself. It is distinctly agreed and
understood that the physicians and their associates named-above shall not be responsible in any way for any consequences resulting from said
diagnostic, medical, and/or surgical treatment and are fully released from all claims and demands whatsoever which way arise, grow out of, or be
incident to such diagnosis, treatment, or surgery insofar as the law allows. I agree to indemnify and hold harmless, the above-named physicians
and their associates, representatives, officers, and agents from any and all consequences of such treatment, diagnosis, or surgery provided these
duties are performed with ordinary care and to the best of their ability
The information above is accurate and complete to the best of my knowledge
Applicant Signature (required) Date
Parent/Guardian Signature
Date
(Required, if applicant is under 18 years of age)
The following is a chart summarizing the height and weight requirements and limitations for those wishing to
ArrowCorps
take part in the Boy Scouts of America’s Order of the Arrow
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Summer Program.
HEIGHT
WEIGHT (POUNDS)
FT
IN RECOMMENDED MAX
5'
0"
97-138
166
5'
1"
101-143
172
5'
2"
104-148
178
5'
3"
107-152
183
5'
4"
111-157
189
5'
5"
114-162
195
5'
6"
118-167
201
5'
7"
121-172
207
5'
8"
125-178
214
5'
9"
129-185
220
5'
10"
132-188
226
5'
11"
136-194
233
6'
0"
140-199
239
6'
1"
144-205
246
6'
2"
148-210
252
6'
3"
152-216
260
6'
4"
156-222
267
6'
5"
160-228
274
6'
6"
164-234
281
6'
7"
170-240
295
This table is based on the revised Dietary Guidelines for Americans from the U.S. Department of Agriculture and the
Department of Health and Human Services.
ArrowCorps
The
Medical Staff reserves the right to deny participation of any individual
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due to extenuating medical conditions or failure to meet medical requirements.
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