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Blank Bsa 680 001 PDF Template

The BSA 680-001 form, essential for Boy Scouts of America high-adventure activities, is subdivided into three parts: Informed Consent, Release Agreement, and Authorization; General Information/Health History; and Pre-Participation Physical. This comprehensive form ensures that participants are medically and physically prepared for the challenges ahead, while also providing vital health information and emergency contact details. Ready to embark on an unforgettable journey? Feel confident in your preparation by filling out the BSA 680-001 form. Click the button below to begin.

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The BSA 680-001 form is an integral document that ensures participants of Scouting programs are medically and physically prepared and informed before taking part in various activities, especially those involving high adventure bases. This comprehensive form is divided into parts A, B1, B2, and C, each serving a unique purpose from providing informed consent and medical information to detailing physical examination results by certified health professionals. Part A focuses on informed consent, release agreement, and authorization, highlighting the voluntary nature of participation and the inherent risks involved, including personal injury and the potential for death. It requires participants or their guardians to consent knowingly to these conditions, authorize emergency medical treatments, and agree to the use of media captured during Scouting activities. Part B is segmented into B1 and B2, collecting detailed health history, medication use, immunization records, and allergy information to ensure the safety and well-being of participants during their Scouting experience. Part C, the pre-participation physical section, must be completed by a licensed health care provider, confirming the participant's medical fitness for involvement in Scouting adventures. This form also addresses the necessity of meeting specific health and fitness criteria to partake in high-adventure programs, emphasizing weight and height restrictions, control of chronic conditions, and ensuring participants bring sufficient medications for their duration at the camp. Through this form, the Boy Scouts of America aim to foster a safe and prepared environment for all individuals engaging in their programs, safeguarding both their physical health and their engaging, enriching experience in Scouting activities.

Preview - Bsa 680 001 Form

Part A: Informed Consent, Release Agreement, and Authorization

Full name: ___________________________________________

Date of birth: _________________________________________

High-adventure base participants:

Expedition/crew No.: _______________________________________________

or staff position:___________________________________________________

Informed Consent, Release Agreement, and Authorization

I understand that participation in Scouting activities involves the risk of personal injury, including death, due to the physical, mental, and emotional challenges in the activities offered. Information about those activities may be obtained from the venue, activity coordinators, or your local council. I also understand that participation in these activities is entirely voluntary and requires participants to follow instructions and abide by all applicable rules and the standards of conduct.

In case of an emergency involving me or my child, I understand that efforts will be made to contact the individual listed as the emergency contact person by the medical provider and/or adult leader. 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.

(If applicable) I have carefully considered the risk involved and hereby give my informed consent for my child to participate in all activities offered in the program. I further authorize the sharing of the information on this form with any BSA volunteers or professionals who need to know of medical conditions that may require special consideration in conducting Scouting activities.

With appreciation of the dangers and risks associated with programs and activities, on my own behalf and/or on behalf of my child, I hereby fully and completely release and waive any and all claims for personal injury, death, or loss that may arise against the Boy Scouts of America, the local council, the activity coordinators, and all employees, volunteers, related parties, or other organizations associated with any program or activity.

I also hereby assign and grant to the local council and the Boy Scouts of America, as well as their authorized representatives, 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 further 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 BSA, and I specifically waive any right to any compensation I may have for any of the foregoing.

Every person who furnishes any BB device to any minor, without the express or implied permission of the parent or legal guardian of the minor, is guilty of a misdemeanor. (California Penal Code

Section 19915[a]) My signature below on this form indicates my permission.

I give permission for my child to use a BB device. (Note: Not all events will include BB devices.)

Checking this box indicates you DO NOT want your child to use a BB device.

NOTE: Due to the nature of programs and activities, the Boy Scouts of America and local councils cannot continually monitor compliance of program participants or any limitations imposed upon them by parents or medical providers. However, so that leaders can be as familiar as possible with any limitations, list any restrictions imposed on a child participant in connection with programs or activities below.

List participant restrictions, if any: None

________________________________________________________

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 Scout Ranch, Philmont Training Center, Northern Tier, Sea Base, or the Summit Bechtel Reserve, I have also read and understand the supplemental risk advisories, 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.

Participant’s signature:____________________________________________________________________________________________ Date: ______________________________

Parent/guardian signature for youth: __________________________________________________________________________________ Date: ______________________________

(If participant is under the age of 18)

Complete this section for youth participants only:

Adults Authorized to Take Youth to and From Events:

You must designate at least one adult. Please include a phone number.

Name: _________________________________________________________________	Name: _________________________________________________________________
Phone: _________________________________________________________________	Phone: _________________________________________________________________

Adults NOT Authorized to Take Youth to and From Events:

Name: _________________________________________________________________	Name: _________________________________________________________________
Phone: _________________________________________________________________	Phone: _________________________________________________________________

680-001

2019 Printing

Part B1: General Information/Health History

Full name: ___________________________________________

Date of birth: _________________________________________

High-adventure base participants:

Expedition/crew No.: _______________________________________________

or staff position:___________________________________________________

Age: ____________________________ Gender: __________________________ Height (inches): ___________________________ Weight (lbs.): ____________________________

Address: _________________________________________________________________________________________________________________________________________

City: ___________________________________________State: ____________________________ ZIP code: __________________ Phone: ______________________________

Unit leader: ____________________________________________________________________________ Unit leader’s mobile #:_________________________________________

Council Name/No.: _______________________________________________________________________________________________________Unit No.: ____________________

Health/Accident Insurance Company: ________________________________________________________ Policy No.: ___________________________________________________

Please attach a photocopy of both sides of the insurance card. If you do not have medical insurance, enter “none” above.

In case of emergency, notify the person below:

Name:______________________________________________________________________________Relationship: ___________________________________________________

Address: _________________________________________________________________ Home phone: _________________________ Other phone: _________________________

Alternate contact name: _________________________________________________________________ Alternate’s phone: ______________________________________________

Health History

Do you currently have or have you ever been treated for any of the following?

Yes	No	Condition					Explain
		Diabetes	Last HbA1c percentage and date:				Insulin pump: Yes  No 

		Hypertension (high blood pressure)

		Adult or congenital heart disease/heart attack/chest pain (angina)/
		heart murmur/coronary artery disease. Any heart surgery or
		procedure. Explain all “yes” answers.

		Family history of heart disease or any sudden heart-related
		death of a family member before age 50.

		Stroke/TIA

		Asthma/reactive airway disease	Last attack date:

		Lung/respiratory disease

		COPD

		Ear/eyes/nose/sinus problems

		Muscular/skeletal condition/muscle or bone issues

		Head injury/concussion/TBI

		Altitude sickness

		Psychiatric/psychological or emotional difficulties

		Neurological/behavioral disorders

		Blood disorders/sickle cell disease

		Fainting spells and dizziness

		Kidney disease

		Seizures or epilepsy	Last seizure date:

		Abdominal/stomach/digestive problems

		Thyroid disease

		Skin issues


		Obstructive sleep apnea/sleep disorders	CPAP: Yes		No	

		List all surgeries and hospitalizations	Last surgery date:

		List any other medical conditions not covered above

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Part B2: General Information/Health History

Full name: ___________________________________________

Date of birth: _________________________________________

High-adventure base participants:

Expedition/crew No.: _______________________________________________

or staff position:___________________________________________________

Allergies/Medications

DO YOU USE AN EPINEPHRINE YES  NO

AUTOINJECTOR? Exp. date (if yes) ___________________________

Are you allergic to or do you have any adverse reaction to any of the following?

Yes	No	Allergies or Reactions	Explain

Medication

Food

DO YOU USE AN ASTHMA RESCUE YES  NO

INHALER? Exp. date (if yes) ___________________________________

Yes	No	Allergies or Reactions	Explain

		Plants


		Insect bites/stings
		Insect bites/stings

List all medications currently used, including any over-the-counter medications.

Check here if no medications are routinely taken.

If additional space is needed, please list on a separate sheet and attach.

Medication

Dose

Frequency

Reason

 YES NO

Non-prescription medication administration is authorized with these exceptions: ________________________________________________________________

Administration of the above medications is approved for youth by:

_______________________________________________________________________ / _______________________________________________________________________

Parent/guardian signature

MD/DO, NP, or PA signature (if your state requires signature)

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.

Immunization

The following immunizations are recommended. Tetanus immunization is required and must have been received within the last 10 years. If you had the disease, check the disease column and list the date. If immunized, check yes and provide the year received.

Yes	No	Had Disease	Immunization	Date(s)

Tetanus

Pertussis

Diphtheria

Measles/mumps/rubella

Polio

Chicken Pox

Hepatitis A

Hepatitis B

Meningitis

Influenza

Other (i.e., HIB)

Exemption to immunizations (form required)

Please list any additional information about your medical history:

_________________________________________

DO NOT WRITE IN THIS BOX.

Review for camp or special activity.

Reviewed by: ___________________________________________

Date: _________________________________________________

Further approval required: Yes  No

Reason: _______________________________________________

Approved by:____________________________________________

Date: _________________________________________________

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2019 Printing

Part C: Pre-Participation Physical

This part must be completed by certified and licensed physicians (MD, DO), nurse practitioners, or physician assistants.

Full name: ___________________________________________

Date of birth: _________________________________________

High-adventure base participants:

Expedition/crew No.: _______________________________________________

or staff position:___________________________________________________

You are being asked to certify that this individual has no contraindication for participation in a Scouting experience. For individuals who will be attending a high-adventure program, including one of the national high-adventure bases, please refer to the supplemental information on the following pages or the form provided by your patient. You can also visit www.scouting.org/health-and-safety/ahmr to view this information online.

Please fill in the following information:

Yes

Explain

Medical restrictions to participate

Yes

Allergies or Reactions

Explain

Yes

Allergies or Reactions

Explain

Medication

Plants

Food

Insect bites/stings

Height (inches)

Weight (lbs.)

BMI

Blood Pressure

Pulse

Normal

Abnormal

Explain Abnormalities

Examiner’s Certification

I certify that I have reviewed the health history and examined this person and find

no contraindications for

Eyes

participation in a Scouting experience. This participant (with noted restrictions):

True

False

Explain

Ears/nose/throat

Meets height/weight requirements.

Lungs

Has no uncontrolled heart disease, lung disease, or hypertension.

Has not had an orthopedic injury, musculoskeletal problems, or orthopedic

Heart

surgery in the last six months or possesses a letter of clearance from his or her

orthopedic surgeon or treating physician.

Has no uncontrolled psychiatric disorders.

Abdomen

Has had no seizures in the last year.

Genitalia/hernia

Does not have poorly controlled diabetes.

If planning to scuba dive, does not have diabetes, asthma, or seizures.

Musculoskeletal

Examiner’s signature: _______________________________________ Date: _______________

Neurological

Examiner’s printed name: _________________________________________________________

Address: _______________________________________________________________________

Skin issues

City: ______________________________________State: ______________ ZIP code: _________

Other

Office phone:___________________________________________________

Height/Weight Restrictions

If you exceed the maximum weight for height as explained in the following chart and your planned high-adventure activity will take you more than 30 minutes away from an emergency vehicle/ accessible roadway, you may not be allowed to participate.

Maximum weight for height:

Height (inches)	Max. Weight		Height (inches)	Max. Weight	Height (inches)	Max. Weight		Height (inches)	Max. Weight

60	166	65		195	70	226	75		260

61	172	66		201	71	233	76		267

62	178	67		207	72	239	77		274

63	183	68		214	73	246	78		281

64	189	69		220	74	252		79 and over	295

680-001

2019 Printing

	High-Adventure Risk Advisory to	Summit Bechtel Reserve
	Health-Care Providers and Parents

	Phone: 304-465-2800 Website: www.summithighadventure.org

The Summit Bechtel Family National Scout Reserve requires that the following supplemental information be shared with the parents and/or guardians and examining health-care providers of every participant. Participants who cannot meet these guidelines will be sent home at their own expense.

The Summit. Activities at the Summit require a certain level of fitness and some can be very physically, mentally, and emotionally demanding. The programs can include mountain biking, BMX biking, skateboarding, rock climbing, zip lines, challenge courses, shooting, archery, whitewater rafting, and kayaking. Depending on the program(s) you select, you will need to arrive at the Summit physically prepared to participate in those activities. The average walk is 5–7 miles a day on uneven terrain with significant changes in elevation. The heat index often reaches almost 100 degrees in the summer. Be prepared!

It is recommended that every participant review information about the Summit Bechtel Reserve at www.summitbsa.org and learn about the program activities that have been selected for participation. Answers to many frequently asked questions can be found at the Summit website. Additional questions can be emailed to summit.program@scouting.org, or you may call 304-465-2800.

Allergy or Anaphylaxis. Participants who have had an anaphylactic reaction due to any cause MUST contact the Summit Bechtel Reserve before arrival. If you are allowed to participate, you will be required to have appropriate treatment with you. The individual and at least one other member of the group must know how to administer the treatment. If you do not bring appropriate treatment with you, you will be required to buy it before you will be allowed

to participate.

Asthma. Asthma must be well-controlled before participating. This means:

1)the use of a rescue inhaler (albuterol) less than two times per week (except

use for the prevention of exercise-induced asthma); 2) nighttime awakenings for asthma symptoms less than two times per month. Well-controlled asthma may include the use of long-acting bronchodilators, inhaled steroids, or oral medications such as Singulair. You may not be allowed to participate if: 1) you have asthma not controlled by medication; or 2) you have been hospitalized/gone to the emergency room to treat asthma in the past six months; or 3) you have needed treatment by oral steroids (prednisone) in the past six months. You must bring an ample supply of your medication and a spare rescue inhaler that are not expired. At least one other member of the crew should know how to use the rescue inhaler. Any person who has needed treatment for asthma in the past three years must carry a rescue inhaler on the trek. If you do not bring a rescue inhaler, you must buy one before you will be allowed to participate.

Immunizations. Each participant must have received a tetanus immunization within the last 10 years. Recognition will be given to participants who do not have a specific immunization because of philosophical, political, or religious beliefs. In such a situation, the Immunization Exemption Request form should be obtained by emailing summit.program@scouting.org.

Seizure Disorder. A seizure disorder or epilepsy does not exclude an individual from participation; however, the disorder must be well controlled with medication. A well-controlled disorder is one in which a year has passed without a seizure. Exceptions to this guideline may be considered on an individual basis.

Recent Musculoskeletal Injuries or

Orthopedic Surgery. Participants at the Summit will put a great deal of strain on their joints and skeletal structure. Individuals with significant musculoskeletal problems (including back problems) or orthopedic surgery within the last six months must have a letter of clearance from their treating physician to be considered for approval. These individuals should contact the Summit in advance for approval to participate.

Psychological and Emotional Difficulties.

Medications for these issues must never be stopped prior to or during participation at the Summit. Experience has demonstrated that these issues can be exacerbated when a participant is under stress from physical and mental challenges.

Diabetes. Both the individual with diabetes and one other person in the group must be able to recognize the signs and symptoms of high and low blood sugar. An insulin-dependent person who has been newly diagnosed or who has undergone a change in their delivery system must have a letter from their treating physician to participate. A recent HbA1c within the last six months is required for diabetic participants.

Hypertension (High Blood Pressure). High blood

pressure should be well controlled with medication. Medication should be continued as prescribed while participating at the Summit. Individuals should have a blood pressure of less than 140/90 to participate.

Medication. Each participant who needs medication must bring enough medicine for the duration of the trip, and that medicine must not have expired. Taking prescription medication is the responsibility of the individual taking the medication and/or that individual’s parent or guardian. A leader, after obtaining all the necessary information, can agree to accept responsibility for ensuring a youth takes necessary medication in accordance with the appropriate schedule. Medications should be secured in locked storage, according to National Camp Accreditation Program Standard HS-08, except for medications carried by the individual for emergent conditions (inhalers, EpiPens, etc.). Participants should consider bringing two or three supplies of vital medication. Participants with allergies that have resulted in severe reactions or anaphylaxis must bring an EpiPen that has not expired. Summit-supplied medications shall be administered and/or dispensed in accordance with preapproved medical procedures. Participants will be charged for maintenance medications not brought to the Summit that are supplied by the Summit Health Lodge.

680-001 October 2019

	High-Adventure Risk Advisory to	Summit Bechtel Reserve
	Health-Care Providers and Parents

	Phone: 304-465-2800 Website: www.summithighadventure.org

Recommendations for Chronic Illnesses.

Adults or youth with any of the following conditions should undergo an evaluation by a physician before considering participation at the Summit.

1.	Chest pain, myocardial infarction (heart attack), or family history of heart
	disease in any person before age 50
2.	Congestive heart failure
3.	Heart surgery, including angioplasty (balloon dilation), to treat blocked blood
	vessels or place stents
4.	Stroke or transient ischemic attacks (TIAs)
5.	High blood pressure
6.	Claudication (leg pain with exercise, caused by hardening of
	the arteries)

Participants age 21 and older who exceed the maximum acceptable weight limit for their height at the Summit medical recheck WILL NOT be permitted to participate in offsite high-adventure programming, but they will have the option of participating in onsite programming if it is available. Summit staff will use their judgment to determine whether those under age 21 who exceed the maximum acceptable weight for their height can participate. The Summit may accept up to 20 pounds over the maximum; however, such exceptions are not made automatically, and discussion with Summit staff in advance will be required by calling

304-465-2800. Please consult the individual program information for weight restrictions due to equipment.

Height/Weight Restrictions. If you exceed the maximum

weight for height as explained in the following chart and your planned high- adventure activity will take you more than 30 minutes away from an emergency vehicle/accessible roadway, you may not be allowed to participate.

7.	Diabetes
8.	Smoking
9.	Excessive weight

Physical exertion at the Summit could precipitate either a heart attack or a stroke in someone who is susceptible. Individuals with a history of any of the conditions listed above should consult their physician to see whether participating in vigorous activities like those at the Summit could exacerbate their condition.

Weight Limits. Weight limit guidelines are used because individuals who are overweight have a greater risk of heart disease, high blood pressure, stroke, altitude sickness, sleep problems, and injuries. These guidelines are for all

Height (inches)

Max. Weight

60166

61172

62178

63183

64189

65195

66201

67207

68214

69220

Height (inches)

Max. Weight

70226

71233

72239

73246

74252

75260

76267

77274

78281

79 and over

295

Scouting high-adventure activities. Each participant’s weight must be at or less than the maximum acceptable weight in the height/weight chart. Anyone exceeding the maximum weight for their height will require further review by the Summit.

Summit Approval. The staff and/or staff physicians reserve the right to deny participation of any individual on the basis of medical history and/or a physical examination. Each individual participant is subject to a medical recheck at the Summit if indicated.

680-001 October 2019

Download Bsa 680 001 PDF Form

Form Data

Fact Name	Description
Form Objective	The BSA 680-001 form serves as Informed Consent, Release Agreement, and Authorization for participants in scouting activities, acknowledging the risks involved and authorizing medical treatment in emergencies.
Parts Overview	Comprises three parts: Part A for consent and medical authorization, Part B for health history, and Part C for a pre-participation physical examination.
Health Information Protection	Protected Health Information (PHI) under the Standards for Privacy of Individually Identifiable Health Information is addressed, ensuring confidentiality and proper use of medical data.
Media Release Authorization	Includes a section that grants the Boy Scouts of America (BSA) and affiliated entities the right to use and publish media of participants without compensation.
High-Adventure Participation	Outlines specific health and fitness requirements for high-adventure program participants and notes that failure to meet these may prevent participation in activities.
State-Specific Legal Reference	Mentions California Penal Code Section 19915(a) regarding the provision of BB devices to minors, indicating a legal consideration specific to residents or activities in California.

Instructions on Utilizing Bsa 680 001

Filling out the BSA 680-001 form is an essential step in preparing for participation in Scouting events, especially those involving high-adventure activities. This form ensures that all participants have provided informed consent, a medical history, and authorization for medical treatment if necessary. The following step-by-step guide simplifies the process, allowing for a smooth and thorough completion of this important document. Ensuring all parts are correctly filled out is vital for the safety and well-being of the participants.

Start with Part A: Informed Consent, Release Agreement, and Authorization. Enter the participant's full name and date of birth in the designated spaces.
If the participant is involved in a high-adventure base, fill in the expedition/crew number or staff position.
Read the informed consent carefully. Consider the risks associated with the activities and the authorization for medical treatment in case of an emergency.
If applicable, check the box to give permission or to deny permission for the child to use a BB device during the event.
List any restrictions for the participant in the space provided. If there are none, mark the corresponding box.
The participant—or for those under 18, a parent or guardian—must sign and date the bottom of Part A to indicate agreement with the terms outlined.
In Part B1: General Information/Health History, repeat the participant's full name and date of birth.
Complete the high-adventure base participant information, if applicable, along with age, gender, height, weight, and contact information.
Provide detailed health/accident insurance information, including a photocopy of the insurance card if available.
Designate an emergency contact, providing their name, relationship, address, and phone numbers.
Under Health History, answer all questions regarding medical conditions, marking "Yes" or "No" accordingly and providing explanations as needed.
For Part B2: Allergies/Medications, indicate whether an epinephrine auto-injector or asthma rescue inhaler is used, including the expiration date. Detail any allergies and list all current medications, dosages, and frequencies.
Sign and date the authorization for non-prescription medication administration at the bottom of Part B2.
Complete the immunization history section, noting any exemptions as required.
Part C: Pre-Participation Physical must be filled out by a certified and licensed healthcare provider. This section confirms there are no medical contraindications for participation in Scouting activities.
The healthcare provider must review the participant's health history, conduct a physical examination, and certify fitness for participation, including any restrictions.
Finally, make sure the healthcare provider signs and dates Part C, providing their contact information for any follow-up required.

After completing these steps, review the entire form to ensure all information has been provided accurately. Remember, this form plays a crucial role in safeguarding the health and safety of Scouts during their adventures. Once filled out, submit the form to the appropriate Scouting officials before the deadline associated with your event or activity. This preparation will pave the way for a fulfilling and enjoyable Scouting experience.

Obtain Answers on Bsa 680 001

What is the purpose of the BSA 680-001 form?

This form is designed for individuals participating in Boy Scouts of America (BSA) activities, including high-adventure programs at national bases. It gathers health history, provides informed consent, release agreement, and medical authorization necessary for participation. This ensures preparedness for the physical, mental, and emotional challenges these activities present and authorizes emergency medical care if needed.
Who needs to complete the BSA 680-001 form?

Participants of all BSA activities, including youth and adults planning to attend high-adventure bases, must complete this form. It's particularly crucial for those engaging in physically demanding programs to have their health information thoroughly documented for safety.
What information is required in Part A of the form?

Part A requires participant's full name, date of birth, expedition or crew number (if applicable), along with informed consent, medical treatment authorization, photo release, and an approval for using BB devices. It also includes sections on participant restrictions and emergency contact information.
How detailed does the health history in Part B need to be?

Part B asks for comprehensive health information, including general health history, allergies, medications, immunization record, and any additional medical history that may impact the participant's ability to safely engage in activities. Accuracy is vital to ensure participant safety and proper care in case of emergencies.
What are the requirements for the Pre-Participation Physical in Part C?

The physical examination in Part C must be completed by a certified and licensed physician, nurse practitioner, or physician assistant. It includes a certification that the participant has no contraindications for participation, based on a thorough review of their health history and a physical examination. Height, weight, blood pressure, and other health indicators are also assessed to ensure the participant meets the physical requirements for their planned activities.
Are there any specific immunizations required for participation?

Yes, a tetanus immunization within the last 10 years is required for all participants. Other recommended immunizations include pertussis, diphtheria, measles/mumps/rubella, polio, chicken pox, hepatitis A & B, meningitis, and influenza. Exemptions may be requested for participants with philosophical, political, or religious beliefs against immunizations.
How does the form address high-adventure risk advisories?

The form includes additional advisories for participants of high-adventure programs, outlining specific requirements for physical fitness, managing conditions like asthma, diabetes, and allergies, and ensuring that essential medications are brought to the activities. These guidelines aim to maintain the safety and well-being of all participants in more challenging scouting activities.

Common mistakes

One common mistake is not providing complete information in the Informed Consent, Release Agreement, and Authorization section. This includes missing details about the full name or date of birth, which are critical for identifying the participant accurately. It's essential to double-check that all required fields are filled out comprehensively.
Another error occurs in the Health History section, where individuals might overlook or inaccurately report their medical conditions or the medical conditions of their child. This part of the form requires careful attention to ensure that all health-related questions are answered truthfully and in detail, providing explanations where necessary. Omitting information can lead to inadequate preparation or response in case of a medical emergency.
Incorrectly managing the medication list is also a common mistake. The form requires listing all medications currently being taken, including over-the-counter drugs. Failing to specify medication names, dosages, and frequencies can lead to confusion and mismanagement of the participant's healthcare needs during Scout activities. Ensuring that this section is accurate and complete is crucial for the safety and well-being of the participant.
Finally, not adhering to the immunization and allergy information guidelines is a frequent oversight. Participants must specify their tetanus immunization status and list any allergies or reactions to medication, food, plants, and insect bites or stings. Neglecting to provide this information or not bringing sufficient medication, such as an EpiPen for allergies, can pose significant risks during scouting events.
- It’s important to: Review the immunization section carefully, ensuring it's filled out according to the participant's medical records.
- Check the allergy sections thoroughly, including specifying whether an epinephrine autoinjector or asthma inhaler is used, and making sure these items are packed for the scouting event.

Documents used along the form

When managing Scouting activities, particularly those involving high-adventure bases, it's imperative to prepare and organize several key forms and documents in addition to the Bsa 680 001 form. These documents not only ensure compliance with Boy Scouts of America (BSA) policies but also foster a safe and inclusive environment for participants. The importance of these documents cannot be overstated, as they contribute significantly to the overall preparedness and response capability of the leadership during activities.

Medical Consent Form: This legal document authorizes the provision of emergency medical treatment for participants under the age of 18 in the event that a parent or guardian cannot be reached.
Activity Consent Form and Approval by Parents or Legal Guardian: Essential for all trips and outings, it specifies the activities to be undertaken and acknowledges the risks involved.
Annual Health and Medical Record: Required annually for participants involved in all Scouting events, camps, and high-adventure bases, this comprehensive record includes medical history, immunization records, and a wellness check.
Talent Release Form: This document grants the BSA permission to use photographs or video recordings of participants in its publications, videos, and online media.
Incident Report Form: Crucial for documenting any accidents, injuries, or significant incidents that occur during Scouting activities.
Authorization for the Administration of Medication: Used when medications need to be administered during Scouting events, detailing medication, dosage, and timing information.
Camp Staff Application: For those interested in working at a BSA camp, these forms collect personal information, background checks, and qualifications.
Swimming Ability Classification Test: Determines a participant’s swimming ability, which is essential for activities involving water.
Program Registration Forms: Individual or group applications required for participating in specific programs or camps, detailing event-specific information and requirements.

In summary, the coordination and submission of these forms and documents are fundamental to the smooth operation of Scouting programs. They ensure that all participants enjoy a safe, productive, and enjoyable experience, keeping parents, guardians, and leaders well-informed and prepared for any circumstances that may arise during Scouting adventures.

Similar forms

The Medical Information and Release Form often used in schools and sports teams shares similarities with BSA form 680-001, particularly in gathering health history and authorizing medical treatment in emergencies. Both collect detailed health information and require consent to treat in case of an emergency.
Liability Waiver Forms used in various physical activities and events resemble the informed consent and release agreement section of the BSA form. They include clauses that release organizations from liability for personal injuries that may occur during participation.
The Activity Consent Form that parents sign for school field trips is similar in its function to authorize minors to participate in activities, detailing the nature of the activity and any inherent risks, much like Part A of the BSA form.
Photo Release Forms, which grant organizations the right to use photographs or videos taken during events, are echoed in the BSA form, which includes a segment assigning the right to use such media for promotional purposes.
Emergency Contact and Health Insurance Information Forms mirror the segment in the BSA form where it collects emergency contacts, health insurance details, and specific health conditions, ensuring that participants can be appropriately assisted in a crisis.
Immunization Records are required by various institutions for participation in activities, much like the immunization section in Part B of the BSA form. These records help ensure the safety and well-being of all participants in group settings.
The High-Adventure Medical Screening Form, specific to ventures requiring higher physical demands, closely matches the purpose of the health history and pre-participation physical of the BSA form, aiming to ensure participants are physically capable of safely engaging in strenuous activities.

Dos and Don'ts

Filling out forms, especially ones as critical as the BSA 680-001 for participation in Boy Scouts of America high-adventure bases, requires attention to detail and an understanding of the information being requested. This ensures the safety and well-being of all participants. Here are some do’s and don’ts that can guide you through the completion process:

Do:

Read through the entire form before beginning to fill it out. This preparatory step ensures that you understand what information is required and helps in gathering all necessary details prior to filling out the form.
Provide accurate and current medical information. Given the physical demands and risks associated with high-adventure activities, disclosing complete and accurate health data ensures that participants receive appropriate care and adjustments as needed.
Include emergency contact information. In the event of an emergency, having readily available contact details for someone who can make decisions on the participant's behalf is crucial.
Review immunization records and update as necessary. Since certain immunizations are recommended and sometimes required for participation, verify that all immunizations are up to date and accurately recorded on the form.

Don't:

Leave sections incomplete. Every section of the form is designed to collect important information. If a section doesn’t apply, it’s better to mark it as “N/A” rather than leaving it blank, to indicate that it was not overlooked.
Forget to sign and date the form. The form often requires the signatures of both the participant and a parent or guardian if the participant is under 18. Unsigned forms may be considered invalid and could delay participation.
Ignore the need for a physician’s review for Part C. The Pre-Participation Physical section must be completed by a licensed healthcare provider. This step is not just a formality but a crucial safety measure to ensure participants are physically and medically ready for the adventure ahead.
Omit details about medications or allergies. With the range of activities involved in high-adventure programs, it’s essential to provide comprehensive details about any medications being taken or allergies that may affect participation.

Taking the time to thoroughly and accurately complete the BSA 680-001 form not only meets the requirements set forth by the Boy Scouts of America but also contributes to a safer and more enjoyable experience for everyone involved.

Misconceptions

There are several misconceptions regarding the BSA 680-001 form, also known as the Annual Health and Medical Record (AHMR), required by the Boy Scouts of America (BSA) for participation in scouting activities. Here are some common misunderstandings and clarifications:

It's only necessary for high-adventure bases: While Part C of the AHMR, which includes a physical examination, is often associated with high-adventure bases like Philmont Scout Ranch, the entire form is required for participants in all Scouting events, camps, and high-adventure bases to ensure the safety and preparedness of all scouts and leaders.
Medical insurance is mandatory to participate in Scouting activities: The form does request information on health insurance, but lack of medical insurance does not preclude participation in Scouting activities. The form allows for "none" to be entered if the participant does not have medical insurance.
Parents cannot limit the administration of any medication: Part B2 of the form allows parents/guardians to authorize or restrict the administration of non-prescription medication to their child, ensuring control over their child’s medication needs.
Asthma disqualifies participation: While the form asks detailed questions about asthma and other conditions to ensure participant safety, having asthma does not automatically disqualify someone from participating. Proper management and medication allow individuals with asthma to engage safely in Scouting activities.
Immunization records are optional: Immunizations are strongly recommended for the safety of all participants, especially tetanus, which is required within the last 10 years. Participants can request an Immunization Exemption for specific beliefs, but it must be formally requested and approved.
Only physicians can complete Part C: Part C must be completed by a certified and licensed health-care provider, which includes physicians (MD, DO), nurse practitioners, or physician assistants, not just physicians alone. This allows for flexibility in who can conduct the examination.
The form authorizes unrestricted use of photographs and videos: The form includes a section granting the BSA and associated parties the right to use images and recordings for scouting purposes. However, this is specific to scouting activities and includes protections against unauthorized personal or commercial use.
Participants with previous injuries or surgeries are excluded: The form does require information on past surgeries or injuries, especially recent ones, to ensure participant safety. However, clearance from a health-care provider can allow participation, demonstrating that each case is evaluated individually.
All sections must be completed annually: While the AHMR is intended to be updated annually, certain sections such as Part C, the pre-participation physical, might have different validity periods based on state laws or scouting event requirements, emphasizing the need for ongoing communication and updates.

Understanding these clarifications ensures that participants and their families can accurately complete the form, thereby facilitating a safer and more inclusive environment for all scouting activities.

Key takeaways

Filling out the BSA 680-001 form is an essential step in preparing for participation in high-adventure programs and activities within the Boy Scouts of America (BSA). Here are key takeaways to ensure that this form is completed accurately and effectively:

Part A of the form includes Informed Consent, Release Agreement, and Authorization, which acknowledges the risks associated with participating in BSA activities. Participants (or their guardians if under 18) must sign this to participate.
It's crucial to provide emergency contact information and to authorize medical treatment in case the participant cannot give consent during an emergency.
The form requires disclosure of any medical conditions, medications, or allergies that might affect participation in BSA activities, ensuring leaders are aware and can prepare accordingly.
Participants have the option to consent or decline the use of BB devices during events, with this choice needing to be indicated on the form.
Restrictions imposed by parents, guardians, or medical providers must be clearly listed to inform activity leaders of any specific needs or limitations.
Part B delves into General Information/Health History, where detailed health information, medical history, and immunization records need to be provided to assess fitness for participation.
All medications, whether prescription or over-the-counter, must be listed with dosage and frequency, reinforcing the importance of managing health conditions during BSA activities.
Immunizations are crucial, with a specific focus on tetanus being required within the last 10 years, and participants are urged to bring sufficient supplies of any medications.
Part C, the Pre-Participation Physical, must be completed by a certified health care provider, ensuring that the participant is physically and medically fit for the activities planned.
Height and weight restrictions apply, especially for high-adventure activities, underscoring the necessity of meeting these requirements for safe participation.

Finally, it's important to directly contact the BSA or high-adventure program for clarification regarding any parts of the form or to discuss specific concerns related to health conditions or participation limitations. Proactive communication helps in tailoring the experience to ensure safety and enjoyment for all participants.

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