2011 Moe Cub Scout Day Camp - Individual Registration Form & Medical

8/7/2019 2011 Moe Cub Scout Day Camp - Individual Registration Form & Medical

1/3

900077

CSI: Cub Scout InvestigationMoecomdws District 2011 Day Camp Registration Packet:

INDIVIDUAL PARTICIPANT REGISTRATION FORM

This form MUST be completed for EACH participantPart 1: Select Your Session

Session ONE July 11-13, 2011 @ Camp Butler in Peninsula, Ohio

Session TWO - July 14-16, 2011 @ Camp Butler in Peninsula, Ohio

Part 2: Indicate TYPE of Participant

Cub Scout Adult Chaperone (No Charge)

Participating Sibling Non-Participating Sibling (No Charge)

NOTE: Siblings are NOT covered under BSA insurance!

Part 3: Registrant Information (Please PRINT)

Pack Number:Cub Scout Rank

This Fall:

Registrant Name: Address:

City, Zip Code: Date of Birth:

E-Mail Address: Home Phone:

T-Shirt Size: Cell Phone:

T-shirts for Cub Scouts and participating siblings are included in the registration fee. Adult chaperones may purchase at-shirt for $10.00 (size 2XL & 3XL for $12.00). Sizes available: YS, YM, YL, AM, AL, AXL, A2XL, and A3XL.

Part 4: Fees

$60.00 for a Scout or participating sibling if registering by May 31, 2011.

$70.00 for a Scout or participating sibling if registering after May 31, 2011.

$3.00 per person - excluding Scout & Participating Siblings - for last day Family Meal. PleaseNOTE the TOTAL # of people attending (excluding Scouts & Participating Sibs) here: _______

NO registrations will be accepted after June 17, 2011 Next Steps: Make check payable to YOUR PACK. Submit completed registration form(s), BSA HealthForm(s), Camper Early Release Form(s), and appropriate payment to your Packs Day CampCoordinator prior to the deadline!


2/3

High-adventure base participants:Expedition/crewNo.: __________________________________________________

orstaffposition:_______________________________________________________

680-02010PrintRev.11/20

Fullname:__________________

_______________DOB:________

______Allergies:__________________Emergencycontact

No.:___________________

Annual BSA Health and Medical RecordPart AGENERAL INFORMATION

Name ___________________________________________________________________ Date o birth ________________________________ Age _____________ Male Female

Address _________________________________________________________________________________________________________________________ Grade completed (youth only) _______

City _____________________________________________________________________ State ____________ Zip ____________________________ Phone No. _____________________________

Unit leader ______________________________________________________ Council name/No. ___________________________________________ Unit No. _________________

Social Security No. (optional; may be required by medical acilities or treatment)_______________________Religiouspreference ____________________________

Health/accident insurance company __________________________________________________________ Policy No. _____________________________________________________

ATTACH A PHOTOCOPY OF BOTH SIDES OF INSURANCE CARD. IF FAMILY HAS NO MEDICAL INSURANCE, STATE NONE.

Incaseofemergency,notify:

Name _________________________________________________________________________________ Relationship ___________________________________________________________

Address _______________________________________________________________________________________________________________________________________________________________

Home phone _________________________________________ Business phone _______________________________ Cell phone ________________________________________

Alternate contact _________________________________________________________________________ Alternates phone _________________________________________________

HEALTH HISTORY

Areyounow,orhaveyoueverbeentreatedforanyofthefollowing: Allergies or Reaction to:

Yes No Condition Explain Medication ___________________________________

Food, Plants, or Insect Bites ________________

________________________________________________

Immunizations:

The ollowing are recommended by the BSA.

Tetanus immunization is required and mus

have been received within the last 10 years.

had disease, put D and the year. If immunize

check the box and the year received.

Yes No Date

Tetanus _______________________

Pertussis ______________________

Diphtheria _____________________

Measles _______________________

Mumps ________________________

Rubella ________________________

Polio ___________________________

Chicken pox___________________

Hepatitis A ____________________

Hepatitis B ____________________

Infuenza ______________________

Other (i.e., HIB) _______________

Exemption to immunizations claimed(orm required).

Asthma Lastattack: ____________

Diabetes LastHbA1c:____________

Hypertension (high blood pressure)

Heart disease (e.g., CHF, CAD, MI)

Stroke/TIA

Lung/respiratory disease

Ear/sinus problems

Muscular/skeletal condition

Menstrual problems (women only)

Psychiatric/psychological andemotional diculties

Behavioral disorders (e.g., ADD,ADHD, Asperger syndrome, autism)

Bleeding disorders

Fainting spells

Thyroid disease

Kidney disease

Sickle cell disease

Seizures Lastseizure:____________Sleep disorders (e.g., sleep apnea) UseCPAP:Yes No

Abdominal/digestive problems

Surgery

Serious injury

Other

MEDICATIONS

List all medications currently used. (I additional space is needed, please photocopythis part o the health orm.) Inhalers and EpiPen inormation must be included, eveni they are or occasional or emergency use only.

Medication _____________________________

Strength ________ Frequency ____________

Approximate date started ________________

Reasonformedication ___________________________________________________________

Medication _____________________________




Medication _____________________________




Medication _____________________________



Reasonformedication ___________________

________________________________________

Medication _____________________________




________________________________________

Medication _____________________________




________________________________________

Administrationoftheabovemedicationsisapprovedby(ifrequiredbyyourstate): ________________________/ _____________________Parent/guardian signature and/or MD/DO, NP, or PA signatu

Be sure to bring medications in sufcient quantities and the original containers. Make sure that they are NOTexpired, including inhalers and EpiPens. You SHOULD NOT STOP taking any maintenance medication.

(For more inormation about immunizationas well as the immunization exemption ormseeScouting Saely on Scouting.org.)

asf
http://www.scouting.org/filestore/pdf/680-451.pdfhttp://www.scouting.org/scoutsource/HealthandSafety.aspxhttp://www.scouting.org/filestore/pdf/680-451.pdfhttp://www.scouting.org/scoutsource/HealthandSafety.aspx


3/3

High-adventure base participants:Expedition/crewNo.: __________________________________________________

orstaffposition:_______________________________________________________

680-02010PrintRev.11/20

Part B

INFORMED CONSENT AND HOLD HARMLESS/RELEASE AGREEMENT

I understand that participation in Scouting activities involves a certain degree o risk and can be physically, mentally, and emotionallydemanding. I also understand that participation in these activities is entirely voluntary and requires participants to abide by applicablerules and standards o conduct.

In case o an emergency involving me or my child, I understand that every eort will be made to contact the individual listed as theemergency contact person. In the event that this person cannot be reached, permission is hereby given to the medical providerselected by the adult leader in charge to secure proper treatment, including hospitalization,anesthesia, surgery, or injections omedication or me or my child. Medical providers are authorized to disclose protected health inormation to the adult in charge, campmedical sta, camp management, and/or any physician or health care provider involved in providing medical care to the participant.Protected Health Inormation/Condential Health Inormation (PHI/CHI) under the Standards or Privacy o Individually IdentiableHealthInformation,45C.F.R.160.103,164.501,etc.seq.,asamendedfromtimetotime,includesexaminationndings, test results,and treatment provided or purposes o medical evaluation o the participant, ollow-up and communication with theparticipantsparents or guardian, and/or determination o the participants ability to continue in the program activities.

I have careully considered the risk involved and give consent or mysel and/or my child to participate in these activities. I approvethe sharing o the inormation on this orm with BSA volunteers and proessionals who need to know o medical situations that mightrequire special consideration or the sae conducting o Scouting activities.

I release the Boy Scouts o America, the local council, the activity coordinators, and all employees, volunteers, related parties, or otherorganizations associated with the activity rom any and all claims or liability arising out o this participation.

Without restrictions.

With special considerations or restrictions (list) ____________________________________________________________________________________________

____________________________________________________________________________________________________________________________________________________

TALENT RELEASE AGREEMENT

I hereby assign and grant to the local council and the Boy Scouts o America the right and permission to use and publish the photographs/lm/videotapes/electronic representations and/or sound recordings made o me or my child at all Scouting activities, and I herebyrelease the Boy Scouts o America, the local council, the activity coordinators, and all employees, volunteers, related parties, or otherorganizations associated with the activity rom any and all liability rom such use and publication.

I hereby authorize the reproduction, sale, copyright, exhibit, broadcast, electronic storage, and/or distribution o said photographs/lm/videotapes/electronic representations and/or sound recordings without limitation at the discretion o the Boy Scouts o America,and I specically waive any right to any compensation I may have or any o the oregoing.

Yes No

I understand that, i any inormation I/we have provided is ound to be inaccurate, it may limit and/or eliminate the opportunity

or participation in any event or activity.

I I am participating at Philmont, Philmont Training Center, Northern Tier, or Florida Sea Base: I have also read andunderstand 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 i those requirements are not met.

The participant has permission to engage in all high-adventure activities described, except as specifcally noted by me or the

health-care provider.

Participants name _______________________________________________________________________________________________________

Participants signature __________________________________________________________________ Date ____________________________

Parent/guardians signature ______________________________________________________________ Date ____________________________ (ifparticipantisundertheageof18)

This Annual Health and Medical Record is valid or 12 calendar months.

ADULTS AUTHORIZED TO TAKE YOUTH TO AND FROM EVENTS:

Youmustdesignateatleastoneadult.Pleaseincludeatelephonenumber.

1.Name _________________________________________________________________ Telephone ______________________________________

2. Name _________________________________________________________________ Telephone ______________________________________

3. Name _________________________________________________________________ Telephone ______________________________________

AdultsNOTauthorizedtotakeyouthtoandfromevents:

1.Name __________________________________________________________________________________________________________________

2. Name __________________________________________________________________________________________________________________

3. Name __________________________________________________________________________________________________________________

Part B Full name: ___________________________________________________________ DOB: __________________

Documents

2011 Moe Cub Scout Day Camp - Individual Registration Form & Medical