Camp Wilderness Health Form Submission Roster (Page 4 of 4) in pdf

Camp Wilderness

Health Form Completion Checklist

This checklist is intended to assist unit leaders in assuring the Annual BSA Health and Medical Record

form is complete before presenting at summer camp. The most current form can be found at

Encourage the

scout/scouters/parents to complete the fillable pdf, print the form, and save a copy for future use.

Please take a moment to review forms and check against this list.

Part A

Appropriate boxes checked for Informed Consent and Talent Release

For youth, at least one adult must be listed as authorized to take youth to and from event. Usually

would be trip leader

Participants signature (youth and adult should sign form) and date

Parent/Guardian’s signature and date

Part B

Name

Date of Birth

Age

Address

Grade Completed (for youth)

Unit Leader

Council Name

Unit Number

Insurance Co

Insurance Number

Card Copy if applicable

Emergency contact information to include at least one phone number

Health History section completed

Allergy Information completed

Immunization section completed- Dates must be written on this form. “up to date” is not acceptable.

Tetanus Date must be within 10 years of date camp begins. If claiming an exemption to immunizations,

exemption form must be attached. In the past, many forms have had immunization records attached.

This is helpful, but you can help to speed up the review process by writing the dates of the

immunizations in the appropriate spots on the health form.

Medication section completed for all medications to be taken at camp. If parents wish to allow camp to

administer over the counter medications such as acetaminophen, ibuprofen, etc. the parent should sign

the section allowing for medication administration.

Part C

Information completed by healthcare provider. No attached school or sports physicals accepted

Restrictions section must show restrictions or the word NONE

Provider information complete

Provider Signature, form must be signed by an Physician (MD or DO), Nurse Practitioner or Physician

Assistant. In accordance with National BSA policy, Chiropractors may not sign health forms.

Date must be within 12 calendar months of your date for camp.

Camp Wilderness Health Form Submission Roster Page 4