Three Fires Council Cub Summer Camp Program Health Advisory And Accommodation Form For Campers With Special Medical Issues/needs

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Boy Scouts of America
Three Fires Council
Health Advisory and Accommodation Form for
Campers with Special Medical Issues/Needs
This form is to be used for youth participants that plan on attending a Three Fires Council Cub Summer Camp Program
that have major health concerns that could limit their full participation or present safety issues. Please complete and
submit this form at least one month prior to camp to alert of the exact concern. A member of our staff will contact
the parent or guardian prior to camp to discuss any requested special accommodations. While we will make every
effort to make reasonable accommodations for the campers safety and participation, in cases of significant issues we
may need to recommend that the child not attend camp. In such cases a full refund will be made. This form does not
replace the BSA Annual Health and Medical Record (#680-001) which is required from all participants.
Name of Youth Participant: ___________________________________________ Camper Age: __________
Pack #: __________ Troop #: ________ Crew#: _____
District: ________________________________
Camp (s) that participant plans to attend: ____________________________________________________
Location: __________________________________
Dates of Camp: __________________________
Health issue:
Severe Allergy: ____Nuts/Peanut ____ Latex ____ Insect stings _______ Other:_______________________
How severe is the allergy: _________________________________________________________________
______________________________________________________________________________________
Will participant bring Epi-pen? ________________
Can they self administer Epi-pen:______________
Mobility Limitations:
____ Wheel Chair
______Crutches or leg cast ___ Other: _______________
Other Health Concerns: _____________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Requested special accommodations: ____________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Will a parent or adult designee be attending camp with the child? ____________________________________

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