Article Guide
The BSA 680 001 form serves as a critical document for participants in Boy Scouts of America (BSA) high-adventure programs, encapsulating essential information about consent, medical history, and emergency contact details. This form is divided into several parts, beginning with an informed consent section that outlines the inherent risks associated with Scouting activities, including potential personal injury or even death. Participants must acknowledge these risks and voluntarily agree to adhere to all rules and standards of conduct. The form also includes a release agreement, which protects the BSA and its affiliates from liability related to injuries or losses that may occur during participation. Furthermore, it requires detailed health history information, allowing medical professionals to assess the participant's fitness for specific activities. This section covers a range of medical conditions, allergies, and medications, ensuring that the organizers can provide appropriate care. Notably, the form also mandates a pre-participation physical examination by a licensed healthcare provider, which certifies that the participant is fit for the physical demands of high-adventure activities. Lastly, the document addresses the use of BB devices, emphasizing parental consent and safety regulations. Collectively, these components ensure that both participants and organizers are well-informed and prepared for a safe and enjoyable experience in the great outdoors.
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Part A: Informed Consent, Release Agreement, and Authorization
A
Full name: ___________________________________________
Date of birth: _________________________________________
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
(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
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: _________________________________________________________________ |
2019 Printing
Part B1: General Information/Health History
Full name: ___________________________________________
Date of birth: _________________________________________
B1
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 |
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Explain |
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Diabetes |
Last HbA1c percentage and date: |
Insulin pump: Yes No |
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Hypertension (high blood pressure) |
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Adult or congenital heart disease/heart attack/chest pain (angina)/ |
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heart murmur/coronary artery disease. Any heart surgery or |
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procedure. Explain all “yes” answers. |
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Family history of heart disease or any sudden |
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death of a family member before age 50. |
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Stroke/TIA |
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Asthma/reactive airway disease |
Last attack date: |
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Lung/respiratory disease |
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COPD |
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Ear/eyes/nose/sinus problems |
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Muscular/skeletal condition/muscle or bone issues |
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Head injury/concussion/TBI |
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Altitude sickness |
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Psychiatric/psychological or emotional difficulties |
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Neurological/behavioral disorders |
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Blood disorders/sickle cell disease |
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Fainting spells and dizziness |
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Kidney disease |
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Seizures or epilepsy |
Last seizure date: |
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Abdominal/stomach/digestive problems |
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Thyroid disease |
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Skin issues |
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Obstructive sleep apnea/sleep disorders |
CPAP: Yes |
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No |
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List all surgeries and hospitalizations |
Last surgery date: |
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List any other medical conditions not covered above |
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2019 Printing
Part B2: General Information/Health History
Full name: ___________________________________________
Date of birth: _________________________________________
B2
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 |
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Medication
Food
DO YOU USE AN ASTHMA RESCUE YES NO
INHALER? Exp. date (if yes) ___________________________________
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Yes |
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No |
Allergies or Reactions |
Explain |
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Plants |
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Insect bites/stings |
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List all medications currently used, including any
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 |
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) |
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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: _________________________________________________
2019 Printing
Form Specifications
| Fact Name | Description |
|---|---|
| Purpose | The BSA 680 001 form is used to obtain informed consent, release agreements, and medical history for participants in Boy Scouts of America activities. |
| Participants | The form is required for all youth and adult participants involved in high-adventure activities organized by the BSA. |
| Emergency Contact | Participants must provide an emergency contact person who can be reached in case of medical emergencies during activities. |
| Medical Authorization | The form authorizes medical providers to disclose protected health information to designated BSA personnel for the purpose of providing care. |
| State-Specific Law | In California, the form includes a provision related to the unlawful furnishing of BB devices to minors (California Penal Code Section 19915(a)). |
| High-Adventure Requirements | Participants must meet specific health and safety requirements, including height and weight restrictions, to engage in high-adventure programs. |
Bsa 680 001: Usage Guidelines
Filling out the BSA 680 001 form is an important step for participants in Scouting activities. The form collects essential information regarding health, emergency contacts, and consent for participation in various programs. It is crucial to provide accurate and complete information to ensure a safe and enjoyable experience.
- Begin with Part A: Informed Consent, Release Agreement, and Authorization. Write your full name and date of birth in the designated spaces.
- Indicate whether you are a participant or staff by filling in the expedition/crew number or your staff position.
- Read the consent and release agreement carefully. Acknowledge your understanding of the risks involved by signing your name and dating the form.
- If applicable, check the box if you do not want your child to use a BB device.
- List any restrictions or limitations for the participant, if any. If there are none, indicate that as well.
- Proceed to Part B1: General Information/Health History. Fill in the participant's full name, date of birth, expedition/crew number or staff position, age, gender, height, weight, and address.
- Provide the phone number and name of the unit leader, along with the council name and unit number.
- List the health and accident insurance company name and policy number. If there is no insurance, write "none."
- In the emergency contact section, fill in the name, relationship, address, and phone numbers of the person to contact in case of an emergency.
- Complete the health history section by answering questions about any medical conditions, allergies, and medications. Provide explanations where necessary.
- Move to Part B2 and answer questions regarding allergies and medications, including whether you use an epinephrine autoinjector or an asthma rescue inhaler.
- List all medications currently being taken, including dosages and reasons for use. If no medications are taken, check the appropriate box.
- In the immunization section, indicate whether the participant has received the recommended immunizations and provide dates where applicable.
- Complete Part C: Pre-Participation Physical by having a certified physician, nurse practitioner, or physician assistant fill out the required information regarding medical restrictions and health status.
- Ensure the examiner signs and dates the section certifying the participant’s eligibility for Scouting activities.
- Finally, review the entire form for completeness and accuracy before submitting it.
Your Questions, Answered
What is the purpose of the BSA 680 001 form?
The BSA 680 001 form is designed to ensure informed consent, release agreements, and medical authorization for participants in Boy Scouts of America (BSA) activities. It collects essential information about participants, including medical history, emergency contacts, and consent for treatment in case of emergencies. This form helps protect both the participants and the organization by outlining the risks involved in scouting activities and ensuring that participants are aware of their responsibilities.
Who needs to complete the BSA 680 001 form?
All participants in BSA activities, especially those involved in high-adventure programs, must complete the BSA 680 001 form. This includes youth members and their parents or guardians if the participant is under 18. The form collects important medical and personal information necessary for safe participation in scouting events.
What information is required on the BSA 680 001 form?
The form requires several pieces of information, including the participant's full name, date of birth, emergency contact details, health history, and consent for medical treatment. Additionally, participants must disclose any existing medical conditions, medications, and allergies. This information is crucial for ensuring the safety and well-being of all participants during scouting activities.
What are the risks associated with participation in BSA activities?
Participation in BSA activities involves various risks, including the potential for personal injury or even death. These risks stem from physical, mental, and emotional challenges inherent in scouting activities. Participants are encouraged to understand these risks fully and to seek information about specific activities from local councils or event coordinators.
What should I do if my child has medical conditions or restrictions?
If your child has any medical conditions or restrictions, it is essential to disclose this information on the BSA 680 001 form. Additionally, you should list any limitations that may affect their participation in activities. This ensures that leaders are aware of your child's needs and can provide appropriate accommodations during events.
How is personal health information protected when completing the form?
The BSA 680 001 form includes provisions for protecting personal health information. Medical providers involved in the care of participants are authorized to share necessary health information with adult leaders and camp medical staff. This sharing is done in accordance with privacy regulations to ensure that participants' health information remains confidential while still allowing for necessary medical care.
Common mistakes
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Incomplete Information: Failing to provide all required personal details, such as full name, date of birth, and emergency contact information, can result in delays or denial of participation.
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Missing Signatures: Not obtaining necessary signatures from a parent or guardian for participants under 18 years of age can invalidate the form.
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Inaccurate Medical History: Providing incorrect or incomplete medical history, including allergies and current medications, may lead to serious health risks during activities.
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Neglecting to Attach Insurance Information: Forgetting to include a photocopy of the insurance card can hinder access to medical care in emergencies.
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Ignoring Restrictions: Failing to list any medical restrictions or limitations can pose safety risks and may affect participation eligibility.
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Overlooking Immunization Requirements: Not ensuring that all required immunizations, particularly the tetanus shot, are up to date can result in disqualification from activities.
Documents used along the form
The BSA 680 001 form is essential for participation in Scouting activities, particularly for high-adventure programs. Along with this form, several other documents are commonly required to ensure participant safety and compliance with health regulations. Below is a list of these additional forms and documents.
- Health History Form: This document collects detailed information about a participant's medical history, including past illnesses, allergies, and current medications. It helps ensure that leaders are aware of any health concerns that may affect participation.
- Pre-Participation Physical Form: This form must be completed by a licensed healthcare provider. It certifies that the participant is physically fit for the activities planned and identifies any medical restrictions that may apply.
- Insurance Information Form: Participants must provide details about their health insurance coverage. This includes the name of the insurance company and policy number, which is crucial in case of an emergency requiring medical attention.
- Emergency Contact Form: This document lists individuals who can be contacted in case of an emergency. It includes names and phone numbers of authorized contacts and is vital for ensuring prompt communication during emergencies.
- Immunization Records: Participants are often required to submit proof of immunizations, particularly for tetanus and other relevant vaccines. This helps protect the health of all participants during Scouting activities.
These documents work together to create a comprehensive safety and health profile for each participant. Ensuring all forms are completed accurately and submitted on time is crucial for a smooth and safe experience in Scouting activities.
Similar forms
- Informed Consent Form: Similar to the BSA 680 001, an informed consent form also requires participants to acknowledge risks associated with an activity. It outlines the nature of the activity and confirms that the participant agrees to proceed voluntarily, understanding the potential dangers involved.
- Medical Release Form: This document authorizes medical personnel to treat an individual in case of an emergency. Like the BSA 680 001, it ensures that medical information is shared with appropriate parties for the participant's safety and care.
- Waiver of Liability: This form releases an organization from responsibility for injuries sustained during an activity. It parallels the BSA 680 001 in that it requires participants to waive their rights to claim damages for injuries incurred while participating in scouting activities.
- Health History Form: Similar to Part B of the BSA 680 001, a health history form collects information about a participant's medical background. This information is crucial for assessing readiness and safety for participation in physical activities.
- Parental Consent Form: This document is often required for minors and ensures that parents or guardians agree to their child's participation. It shares similarities with the BSA 680 001 in that it requires a signature from a parent or guardian, affirming their understanding of the associated risks.
- Emergency Contact Form: This form provides vital information about whom to contact in case of an emergency. Like the BSA 680 001, it ensures that emergency personnel can quickly reach designated individuals if necessary.
Dos and Don'ts
When filling out the BSA 680 001 form, it's important to follow certain guidelines to ensure accuracy and compliance. Here’s a list of things you should and shouldn’t do:
- Do read all instructions carefully before starting.
- Do provide complete and accurate information in all sections.
- Do include emergency contact information that is up-to-date.
- Do ensure that all signatures are obtained where required.
- Do attach a photocopy of your insurance card if applicable.
- Don’t leave any sections blank; fill in all required fields.
- Don’t use nicknames; always use full legal names.
- Don’t provide false or misleading information, as it may affect participation.
- Don’t forget to check the expiration dates on medications listed.
- Don’t ignore any specific medical restrictions or requirements outlined in the form.
Misconceptions
- Misconception 1: The BSA 680 001 form is only for youth participants.
- Misconception 2: Signing the form means participants are waiving all rights to medical care.
- Misconception 3: The form is only about consent and does not cover health history.
- Misconception 4: Parents can ignore medical history questions if their child is healthy.
- Misconception 5: The form is only required for certain high-adventure activities.
- Misconception 6: Participants can use any medication without notifying leaders.
- Misconception 7: Completing the form guarantees a spot in activities.
- Misconception 8: The form does not allow for any exceptions regarding medical conditions.
- Misconception 9: The BSA 680 001 form is a one-time requirement.
This form is necessary for all participants, including adults and staff members. It ensures that everyone involved in Scouting activities is properly informed and consenting to the associated risks.
The form does not waive the right to receive medical care. It allows designated medical personnel to act in emergencies when the emergency contact cannot be reached.
The BSA 680 001 form includes sections for health history, allergies, and medications. This information is vital for ensuring participant safety during activities.
It is essential to complete all medical history questions accurately, even for healthy children. This information helps leaders understand any potential risks during activities.
The BSA 680 001 form is required for all Scouting activities, not just high-adventure ones. This ensures comprehensive safety and consent for every event.
All medications must be disclosed on the form. Participants need to bring enough medication for the duration of the trip and ensure it is not expired.
While the form is necessary for participation, it does not guarantee a spot. Participants must also meet specific health and safety requirements outlined in the form.
While the form sets guidelines, exceptions can be considered on a case-by-case basis, especially for well-managed medical conditions. Communication with leaders is crucial.
This form may need to be updated regularly, especially if there are changes in a participant's health status or medical history. Staying current ensures ongoing safety and compliance.
Key takeaways
Filling out the BSA 680 001 form is an important step for participants in Scouting activities. Here are some key takeaways to keep in mind:
- Informed Consent: Participants and their guardians must understand the risks involved in Scouting activities. This includes acknowledging potential personal injury and the need to follow all rules and instructions.
- Medical Information: Accurate health history is crucial. Participants should disclose any medical conditions, allergies, or medications they are taking to ensure their safety during activities.
- Emergency Contact: It’s essential to provide up-to-date emergency contact information. This allows medical providers to reach someone quickly in case of an emergency.
- Authorization for Treatment: The form includes consent for medical treatment if necessary. Participants or guardians should be aware that medical providers may share health information with relevant personnel for care purposes.