Common use of Immunization Clause in Contracts

Immunization. The following immunizations are recommended by the BSA. 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: 2014 Printing Part C: Pre-Participation Physical C This part must be completed by certified and licensed physicians (MD, DO), nurse practitioners, or physician assistants. High-adventure base participants: Expedition/crew No.: or staff position: Full name: DOB: ! ! You are being asked to certify that this individual has no contraindication for participation inside 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. Examiner: Please fill in the following information: Yes No Explain Medical restrictions to participate Yes No Allergies or Reactions Explain Yes No Allergies or Reactions Explain Medication Plants Food Insect bites/stings Height (inches): Weight (lbs.): BMI: Blood Pressure: / Pulse: Normal Abnormal Explain Abnormalities Eyes Ears/nose/ throat Lungs Heart Abdomen Genitalia/hernia Musculoskeletal Neurological Other Examiner’s Certification I certify that I have reviewed the health history and examined this person and find no contraindications for participation in a Scouting experience. This participant (with noted restrictions): True False Explain Meets height/weight requirements. Does not have uncontrolled heart disease, asthma, or hypertension. Has not had an orthopedic injury, musculoskeletal problems, or orthopedic 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. Has had no seizures in the last year. Does not have poorly controlled diabetes. If less than 18 years of age and planning to scuba dive, does not have diabetes, asthma, or seizures. For high-adventure participants, I have reviewed with them the important supplemental risk advisory provided. Examiner’s Signature: Date: Provider printed name: Address: City: State: ZIP code: 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 60 166 61 172 62 178 63 183 64 189 Height (inches) Max. Weight 65 195 66 201 67 207 68 214 69 220 Height (inches) Max. Weight 70 226 71 233 72 239 73 246 74 252 Height (inches) Max. Weight 75 260 76 267 77 274 78 281 79 and over 295

Immunization. The following immunizations are recommended by the BSA. 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: 2014 Printing Part C: Pre-Participation Physical C This part must be completed by certified and licensed physicians (MD, DO), nurse practitioners, or physician assistants. High-adventure base participants: Expedition/crew No.: or staff position: Full name: DOB: ! ! You are being asked to certify that this individual has no contraindication for participation inside 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. Examiner: Please fill in the following information: Yes No Explain Medical restrictions to participate Yes No Allergies or Reactions Explain Yes No Allergies or Reactions Explain Medication Plants Food Insect bites/stings Height (inches): Weight (lbs.): BMI: Blood Pressure: / Pulse: Normal Abnormal Explain Abnormalities Eyes Ears/nose/ throat Lungs Heart Abdomen Genitalia/hernia Musculoskeletal Neurological Other Examiner’s Certification I certify that I have reviewed the health history and examined this person and find no contraindications for participation in a Scouting experience. This participant (with noted restrictions): True False Explain Meets height/weight requirements. Does not have uncontrolled heart disease, asthma, or hypertension. Has not had an orthopedic injury, musculoskeletal problems, or orthopedic 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. Has had no seizures in the last year. Does not have poorly controlled diabetes. If less than 18 years of age and planning to scuba dive, does not have diabetes, asthma, or seizures. For high-adventure participants, I have reviewed with them the important supplemental risk advisory provided. Examiner’s Signature: Date: Provider printed name: Address: City: State: ZIP code: 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 60 166 61 172 62 178 63 183 64 189 Height (inches) Max. Weight 65 195 66 201 67 207 68 214 69 220 Maximum weight for height: 60 Height (inches) Max. Weight 166 61 172 62 178 63 183 64 189 Height (inches) 260 Max. Weight Height (inches) Max. Weight 70 226 71 233 72 239 73 246 74 252 Height (inches) Max. Weight 75 260 267 76 267 274 77 274 281 78 281 79 and over 295680-001 2014 Printing

Immunization. The following immunizations are recommended by the BSA. 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: 2014 Printing Part C: Pre-Participation Physical C This part must be completed by certified and licensed physicians (MD, DO), nurse practitioners, or physician assistants. High-adventure base participants: Expedition/crew No.: or staff position: Full name: DOB: ! ! You are being asked to certify that this individual has no contraindication for participation inside 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. Examiner: Please fill in the following information: Yes No Explain Medical restrictions to participate Yes No Allergies or Reactions Explain Yes No Allergies or Reactions Explain Medication Plants Food Insect bites/stings Height (inches): Weight (lbs.): BMI: Blood Pressure: / Pulse: Normal Abnormal Explain Abnormalities Eyes Ears/nose/ throat Lungs Heart Abdomen Genitalia/hernia Musculoskeletal Neurological Other Examiner’s Certification I certify that I have reviewed the health history and examined this person and find no contraindications for participation in a Scouting experience. This participant (with noted restrictions): True False Explain Meets height/weight requirements. Does not have uncontrolled heart disease, asthma, or hypertension. Has not had an orthopedic injury, musculoskeletal problems, or orthopedic 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. Has had no seizures in the last year. Does not have poorly controlled diabetes. If less than 18 years of age and planning to scuba dive, does not have diabetes, asthma, or seizures. For high-adventure participants, I have reviewed with them the important supplemental risk advisory provided. Examiner’s Signature: Date: Provider printed name: Address: City: State: ZIP code: 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 60 166 61 172 62 178 63 183 64 189 Height (inches) Max. Weight 65 195 66 201 67 207 68 214 69 220 Maximum weight for height: 60 Height (inches) Max. Weight 166 61 172 62 178 63 183 64 189 Height (inches) 260 Max. Weight Height (inches) Max. Weight 70 226 71 233 72 239 73 246 74 252 Height (inches) Max. Weight 75 260 267 76 267 274 77 274 281 78 281 295 79 and over 295over

Immunization. The following immunizations are recommended by the BSA. 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: 2014 Printing Part C: Pre-Participation Physical C This part must be completed by certified and licensed physicians (MD, DO), nurse practitioners, or physician assistants. High-adventure base participants: Expedition/crew No.: or staff position: Full name: DOB: ! ! You are being asked to certify that this individual has no contraindication for participation inside 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. Examiner: Please fill in the following information: Yes No Explain Medical restrictions to participate Yes No Allergies or Reactions Explain Yes No Allergies or Reactions Explain Medication Plants Food Insect bites/stings Height (inches): Weight (lbs.): BMI: Blood Pressure: / Pulse: Normal Abnormal Explain Abnormalities Eyes Ears/nose/ throat Lungs Heart Abdomen Genitalia/hernia Musculoskeletal Neurological Other Examiner’s Certification I certify that I have reviewed the health history and examined this person and find no contraindications for participation in a Scouting experience. This participant (with noted restrictions): True False Explain Meets height/weight requirements. Does not have uncontrolled heart disease, asthma, or hypertension. Has not had an orthopedic injury, musculoskeletal problems, or orthopedic 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. Has had no seizures in the last year. Does not have poorly controlled diabetes. If less than 18 years of age and planning to scuba dive, does not have diabetes, asthma, or seizures. For high-adventure participants, I have reviewed with them the important supplemental risk advisory provided. Examiner’s Signature: Date: Provider printed name: Address: City: State: ZIP code: 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 60 166 61 172 62 178 63 183 64 189 Height (inches) Max. Weight 65 195 66 201 67 207 68 214 69 220 Height (inches) Max. Weight 70 226 71 233 72 239 73 246 74 252 Height (inches) Max. Weight 75 260 76 267 77 274 78 281 79 and over 295295 680-001 2014 Printing DCS - Camp Chief Little Turtle Medications Administration Record Prescription or Over-the-Counter Medications & Medical Assisted Devices MEDICINE: All medications must be in their ORIGINAL container. Medications not provided in their ORIGINAL container WILL NOT be accepted. Scouts on medications must have a completed medication record sheet signed by their parent upon arrival to camp. PLEASE ONLY bring the amount needed for your stay at CCLT. Those with epi-pens, inhalers, etc. should bring TWO, marked with the Scout’s full name. An extra shall be kept in the Health Lodge as a precaution. All medications will be kept in the Medication Lockbox at the unit’s campsite and will be the responsibility of each unit’s leader. Only those medications that require refrigeration or other temperature controlled storage will be kept in the Health Office. Please complete and return this form w/ your health form to your unit leader. Name: Unit #: Age: Dietary or Medical Concerns: Parent Signature(if needed) Date Over-the-Counter Medication: I authorize the medical staff of Camp Chief Little Turtle to administer the following over-the-counter medications. Please circle your choices. ▶ Anti-histamines ▶ Acetaminophen ▶ Ibuprofen ▶ Cough Drops ▶ Anti-itch cream ▶ Pepto-Bismol tablets ▶ NONE ▶ OTHER:

Immunization. The following immunizations are recommended by the BSA. 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: 2014 Printing Part C: Pre-Participation Physical C This part must be completed by certified and licensed physicians (MD, DO), nurse practitioners, or physician assistants. High-adventure base participants: Expedition/crew No.: or staff position: Full name: DOB: ! ! You are being asked to certify that this individual has no contraindication for participation inside 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. Examiner: Please fill in the following information: Yes No Explain Medical restrictions to participate Yes No Allergies or Reactions Explain Yes No Allergies or Reactions Explain Medication Plants Food Insect bites/stings Height (inches): Weight (lbs.): BMI: Blood Pressure: / Pulse: Normal Abnormal Explain Abnormalities Eyes Ears/nose/ throat Lungs Heart Abdomen Genitalia/hernia Musculoskeletal Neurological Other Examiner’s Certification I certify that I have reviewed the health history and examined this person and find no contraindications for participation in a Scouting experience. This participant (with noted restrictions): True False Explain Meets height/weight requirements. Does not have uncontrolled heart disease, asthma, or hypertension. Has not had an orthopedic injury, musculoskeletal problems, or orthopedic 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. Has had no seizures in the last year. Does not have poorly controlled diabetes. If less than 18 years of age and planning to scuba dive, does not have diabetes, asthma, or seizures. For high-adventure participants, I have reviewed with them the important supplemental risk advisory provided. Examiner’s Signature: Date: Provider printed name: Address: City: State: ZIP code: 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 60 166 61 172 62 178 63 183 64 189 Height (inches) Max. Weight 65 195 66 201 67 207 68 214 69 220 Height (inches) Max. Weight 70 226 71 233 72 239 73 246 74 252 Height (inches) Max. Weight 75 260 76 267 77 274 78 281 79 and over 295295 680-001 2014 Printing Summit Xxxxxxx Reserve High-Adventure Risk Advisory to Health-Care Providers and Parents Phone: 000-000-0000 Website: xxx.xxxxxxxxxxxxxxxxxxx.xxx The Summit Xxxxxxx 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 Experience. High-adventure activities at the Summit are variable and unique. All activities will require a certain level of fitness, and some activities can be very physically, mentally, and emotionally demanding. The program may include mountain biking, BMX biking, skateboarding, rock climbing, zip lines, challenge courses, shooting, archery, whitewater rafting, and kayaking. Depending on the high-adventure programs you select, you will need to arrive at the Summit physically prepared to participate in those activities. A body mass index (BMI) of 32 or less is required to participate in all of the high-adventure activities at the Summit. Those with BMIs of 32 to 40 will require additional documentation from their physicians stating that they are fit to participate in the high-adventure activities for which they have registered. No participant with a BMI greater than 40 will be allowed at the Summit and will be sent home at their own expense. In addition, those intending to visit the Summit should be aware of the conditions there: The average temperature at the Summit from June through August is 60 to 80 degrees, and the humidity averages 70 to 75 percent. Also, the terrain at the Summit is very hilly, and the layout requires considerable walking and effort. Participants will walk several miles a day to get to activity areas. Be prepared! It is recommended that every participant review information about the Summit Xxxxxxx Reserve at xxx.xxxxxxxxxx.xxx 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 xxxxxx.xxxxxxx@xxxxxxxx.xxx, or you may call 000-000-0000.

Immunization. The following immunizations are recommended by the BSA. 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: 2014 Printing Part C: Pre-Participation Physical C This part must be completed by certified and licensed physicians (MD, DO), nurse practitioners, or physician assistants. High-adventure base participants: Expedition/crew No.: or staff position: Full name: DOB: ! ! You are being asked to certify that this individual has no contraindication for participation inside 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. Examiner: Please fill in the following information: Yes No Explain Medical restrictions to participate Yes No Allergies or Reactions Explain Yes No Allergies or Reactions Explain Medication Plants Food Insect bites/stings Height (inches): Weight (lbs.): BMI: Blood Pressure: / Pulse: Normal Abnormal Explain Abnormalities Eyes Ears/nose/ throat Lungs Heart Abdomen Genitalia/hernia Musculoskeletal Neurological Other Examiner’s Certification I certify that I have reviewed the health history and examined this person and find no contraindications for participation in a Scouting experience. This participant (with noted restrictions): True False Explain Meets height/weight requirements. Does not have uncontrolled heart disease, asthma, or hypertension. Has not had an orthopedic injury, musculoskeletal problems, or orthopedic 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. Has had no seizures in the last year. Does not have poorly controlled diabetes. If less than 18 years of age and planning to scuba dive, does not have diabetes, asthma, or seizures. For high-adventure participants, I have reviewed with them the important supplemental risk advisory provided. Examiner’s Signature: Date: Provider printed name: Address: City: State: ZIP code: 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 60 166 61 172 62 178 63 183 64 189 Height (inches) Max. Weight 65 195 66 201 67 207 68 214 69 220 Height (inches) Max. Weight 70 226 71 233 72 239 73 246 74 252 Height (inches) Max. Weight 75 260 76 267 77 274 78 281 79 and over 295295 2014 Printing This page intentionally left blank. SENECA WATERWAYS COUNCIL BOY SCOUTS OF AMERICA Summer Camp Medication Permission Form Last Name: First Name: Unit: Address: Unit Town: Phone: DOB: Weight: Oral Agents Dosage Indication and Schedule Camper Health Care Provider Comments Approval Initials Benadryl (Diphenhydramine) <90# 25 mg >= 90# 50 mg Allergic Reaction/ Hay Fever every six hours as needed for 24 hours Yes No Imodium (Ioperamide) Initial 4 tsp. repeat 2 tsp. Diarrhea as needed for watery stool limit 8 tsp. Yes No Maalox 30 cc Indigestion/ heartburn once Yes No Milk of Magnesia 30 cc Constipation daily twice as needed Yes No Xxxxxxxxxx Per label instructions Colds every six hours as needed Yes No Tylenol (Acetaminophen) 15 mg/kg (below) Fever, Headache, Pain Control, Toothache every 4 hours as needed Yes No Topical Agents Dosage Indication and Schedule Camper Health Care Provider Comments Approval Initials Bacitracin Per label instructions Wound care twice daily and as needed Yes No Caladryl (Pramoxine) Per label instructions Insect Bites/ Poison Ivy twice daily and as needed Yes No Desenex Powder (Miconazole) Per label instructions Athletes Foot twice daily and as needed Yes No Lotrimin (clotrimazole) Per label instructions Jock Itch three times daily Yes No Tylenol Dosing Wt. (pounds) 00-00 00-00 95-150 >150 Dose 325 mg 500 mg 650 mg 1000 mg Prescription or OTC medication Dosage/ Route Indication and Schedule Camper Health Care Provider Comments Self Administration Initials Yes No Yes No Yes No Health Care Provider: Phone: Address: License: Health Care Provider signature: Date: I hereby give permission for my son/ daughter receive over the counter and prescription medications as indicated by my child’s Health Care Provider and request self administration of prescription drugs. In addition, I give permission to carry and use sunscreen or insect repellent at camp and to use it throughout the day. If my child needs help re-applying sunscreen or insect repellent, I give permission for camp staff to provide my child with assistance if he/she requests it. Signature of Parent or Guardian: Date:

Immunization. The following immunizations are recommended by the BSA. 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: 2014 Printing Part C: Pre-Participation Physical C This part must be completed by certified and licensed physicians (MD, DO), nurse practitioners, or physician assistants. High-adventure base participants: Expedition/crew No.: or staff position: Full name: DOB: ! ! You are being asked to certify that this individual has no contraindication for participation inside 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. Examiner: Please fill in the following information: Yes No Explain Medical restrictions to participate Yes No Allergies or Reactions Explain Yes No Allergies or Reactions Explain Medication Plants Food Insect bites/stings Height (inches): Weight (lbs.): BMI: Blood Pressure: / Pulse: Normal Abnormal Explain Abnormalities Eyes Ears/nose/ throat Lungs Heart Abdomen Genitalia/hernia Musculoskeletal Neurological Other Examiner’s Certification I certify that I have reviewed the health history and examined this person and find no contraindications for participation in a Scouting experience. This participant (with noted restrictions): True False Explain Meets height/weight requirements. Does not have uncontrolled heart disease, asthma, or hypertension. Has not had an orthopedic injury, musculoskeletal problems, or orthopedic 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. Has had no seizures in the last year. Does not have poorly controlled diabetes. If less than 18 years of age and planning to scuba dive, does not have diabetes, asthma, or seizures. For high-adventure participants, I have reviewed with them the important supplemental risk advisory provided. Examiner’s Signature: Date: Provider printed name: Address: City: State: ZIP code: 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 60 166 61 172 62 178 63 183 64 189 Height (inches) Max. Weight 65 195 66 201 67 207 68 214 69 220 Height (inches) Max. Weight 70 226 71 233 72 239 73 246 74 252 Height (inches) Max. Weight 75 260 76 267 77 274 78 281 79 and over 295295 680-001 2014 Printing Ten Mile River Scout Camps Greater New York Councils xxx.xxxxxxxxxxxx.xxx Individualized Medication Orders STANDARD OVER-THE-COUNTER/PRN MEDICATIONS CAMPER NAME: UNIT: CAMPER WEIGHT: lbs. DATE OF BIRTH: / / CAMP: HEALTHCARE PROVIDER NAME: LICENSE #: ADDRESS: HEALTHCARE PROVIDER SIGNATURE: I recognize that this is a two-page document DATE: / / HEALTHCARE PROVIDER STAMP: By order of the NYS Department of Health, this form is required for all campers under 18 years of age, and must be accompanied by a completed Annual BSA Health and Medical Record Form. The following medications are available in the camp Health Lodge and will be administered at the discretion of the camp Medical Officer, if approval is ordered by the Healthcare Provider below. Do not send these medications to camp; they are at the Health Lodge DRUG NAME ROUTE circle preferred formulation DOSAGE SCHEDULE PROVIDER ORDER check one COMMENTS BENADRYL (25 to 50 mg) PO (elixir, chewable tabs, pills) Per label instructions by age/weight Q 6 hr prn for allergic reaction (hives, insect bite) 🞎 YES 🞎 NO CEPACOL PO (lozenges) Per label instructions by age/weight Q 2 hr for sore throat (no > 4 doses in 24 hr and no fever) 🞎 YES 🞎 NO CHILDREN’S DIMETAPP COLD & ALLERGY PO (elixir, tabs) Per label instructions by age/weight Q 6-8 hr prn for nasal congestion/drainage 🞎 YES 🞎 NO IBUPROFEN (200 to 400 mg) PO (chewable tabs, suspension, tabs) Per label instructions by age/weight Q 6 hr prn for pain or fever > °F 🞎 YES 🞎 NO MYLANTA PO (chewable tabs) Per label instructions by age/weight TID prn for stomach upset 🞎 YES 🞎 NO CHILDREN’S PEPTO BISMOL PO (liquid, chewable tabs) Per label instructions by age/weight TID prn for stomach upset (no > 4 doses in 24 hr) 🞎 YES 🞎 NO ROBITUSSIN PO (syrup) Per label instructions by age/weight Q 4 hr prn for cough 🞎 YES 🞎 NO v. 1.4 revised 3/2011 Page 1 of 2 Individualized Medication Orders STANDARD OVER-THE-COUNTER/PRN MEDICATIONS CAMPER NAME: UNIT: CAMP: DRUG NAME ROUTE circle preferred formulation DOSAGE SCHEDULE PROVIDER ORDER check one COMMENTS TYLENOL PO (chewable tabs, elixir, tabs) Per label instructions by age/weight Q 4 hr prn for pain or fever > °F 🞎 YES 🞎 NO CALADRYL Topical Per label instructions by age/weight as directed for itches, bites, skin irritations, rashes 🞎 YES 🞎 NO BACITRACIN OINTMENT Topical Per label instructions by age/weight as directed for minor cuts and abrasions 🞎 YES 🞎 NO TINACTIN (or equivalent) Topical (liquid, powder) Per label instructions by age/weight as directed for athlete’s foot, jock itch, fungal rash 🞎 YES 🞎 NO The medications above are the only medications that are available in the camp Health Lodge. If additional over-the-counter medications are required, the camper’s parent/guardian must make arrangements to procure and send these medications to camp with the camper’s unit leader. The Healthcare Provider should list any such medications below. SELF-PROVIDED OVER-THE-COUNTER/PRN MEDICATIONS please strike out this section if not needed 🞎 YES 🞎 NO 🞎 YES 🞎 NO 🞎 YES 🞎 NO v. 1.4 revised 3/2011 Page 2 of 2 NEW YORK STATE DEPARTMENT OF HEALTH Bureau of Communicable Disease Control Meningococcal Disease

Immunization. The following immunizations are recommended by the BSA. 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: 2014 Printing Part C: Pre-Participation Physical C This part must be completed by certified and licensed physicians (MD, DO), nurse practitioners, or physician assistants. High-adventure base participants: Expedition/crew No.: or staff position: Full name: DOB: ! ! You are being asked to certify that this individual has no contraindication for participation inside 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. Examiner: Please fill in the following information: Yes No Explain Medical restrictions to participate Yes No Allergies or Reactions Explain Yes No Allergies or Reactions Explain Medication Plants Food Insect bites/stings Height (inches): Weight (lbs.): BMI: Blood Pressure: / Pulse: Normal Abnormal Explain Abnormalities Eyes Ears/nose/ throat Lungs Heart Abdomen Genitalia/hernia Musculoskeletal Neurological Other Examiner’s Certification I certify that I have reviewed the health history and examined this person and find no contraindications for participation in a Scouting experience. This participant (with noted restrictions): True False Explain Meets height/weight requirements. Does not have uncontrolled heart disease, asthma, or hypertension. Has not had an orthopedic injury, musculoskeletal problems, or orthopedic 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. Has had no seizures in the last year. Does not have poorly controlled diabetes. If less than 18 years of age and planning to scuba dive, does not have diabetes, asthma, or seizures. For high-adventure participants, I have reviewed with them the important supplemental risk advisory provided. Examiner’s Signature: Date: Provider printed name: Address: City: State: ZIP code: 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 60 166 61 172 62 178 63 183 64 189 Height (inches) Max. Weight 65 195 66 201 67 207 68 214 69 220 Maximum weight for height: 60 Height (inches) Max. Weight 166 61 172 62 178 63 183 64 189 Height (inches) 260 Max. Weight Height (inches) Max. Weight 70 226 71 233 72 239 73 246 74 252 Height (inches) Max. Weight 75 260 267 76 267 274 77 274 281 78 281 295 79 and over 295680-001 2014 Printing 000 Xxxxxxxx Xxxxxx St. Xxxx, MN 00000-0000 000-000-0000 Fax: 000-000-0000 0000 Xxxxxxxx Xxxxxx Minneapolis, MN 55422-5118 000-000-0000 Fax: 000-000-0000 xxx.xxxxxxxxxxxxxxx.xxx Permission to Participate in Shooting Sports for all Cub Scouts, Boy Scouts, Venturers and Explorers This permission form must be completed by the participant’s parent or legal guardian prior to any shooting activity. Name of Participant: I, (print your name) xxxxx my consent to Northern Star Council and to its representatives including Range Officers and Instructors and others serving in these positions to furnish my child with archery equipment, firearms and ammunition and provide instruction as to their safe and proper use. I further certify that I am the parent with full parental rights or the legal guardian of this child. I understand that this document will be kept and maintained by the Northern Star Council or its representatives including Range Officers and Instructors. I further understand that any modification of this form will result in its not being accepted by Northern Star Council, Range Officers and Instructors. Signature of Parent or Legal Guardian:

Immunization. The following immunizations are recommended by the BSA. 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: 2014 Printing Part C: Pre-Participation Physical C This part must be completed by certified and licensed physicians (MD, DO), nurse practitioners, or physician assistants. High-adventure base participants: Expedition/crew No.: or staff position: Full name: DOB: ! ! You are being asked to certify that this individual has no contraindication for participation inside 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. Examiner: Please fill in the following information: Yes No Explain Medical restrictions to participate Yes No Allergies or Reactions Explain Yes No Allergies or Reactions Explain Medication Plants Food Insect bites/stings Height (inches): Weight (lbs.): BMI: Blood Pressure: / Pulse: Normal Abnormal Explain Abnormalities Eyes Ears/nose/ throat Lungs Heart Abdomen Genitalia/hernia Musculoskeletal Neurological Other Examiner’s Certification I certify that I have reviewed the health history and examined this person and find no contraindications for participation in a Scouting experience. This participant (with noted restrictions): True False Explain Meets height/weight requirements. Does not have uncontrolled heart disease, asthma, or hypertension. Has not had an orthopedic injury, musculoskeletal problems, or orthopedic 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. Has had no seizures in the last year. Does not have poorly controlled diabetes. If less than 18 years of age and planning to scuba dive, does not have diabetes, asthma, or seizures. For high-adventure participants, I have reviewed with them the important supplemental risk advisory provided. Examiner’s Signature: Date: Provider printed name: Address: City: State: ZIP code: 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 60 166 61 172 62 178 63 183 64 189 Height (inches) Max. Weight 65 195 66 201 67 207 68 214 69 220 Height (inches) Max. Weight 70 226 71 233 72 239 73 246 74 252 Height (inches) Max. Weight 75 260 76 267 77 274 78 281 79 and over 295

Immunization. The following immunizations are recommended by the BSA. 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: 2014 Printing Part C: Pre-Participation Physical C This part must be completed by certified and licensed physicians (MD, DO), nurse practitioners, or physician assistants. High-adventure base participants: Expedition/crew No.: or staff position: Full name: DOB: ! ! You are being asked to certify that this individual has no contraindication for participation inside 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. Examiner: Please fill in the following information: Yes No Explain Medical restrictions to participate Yes No Allergies or Reactions Explain Yes No Allergies or Reactions Explain Medication Plants Food Insect bites/stings Height (inches): Weight (lbs.): BMI: Blood Pressure: / Pulse: Normal Abnormal Explain Abnormalities Eyes Ears/nose/ throat Lungs Heart Abdomen Genitalia/hernia Musculoskeletal Neurological Other Examiner’s Certification I certify that I have reviewed the health history and examined this person and find no contraindications for participation in a Scouting experience. This participant (with noted restrictions): True False Explain Meets height/weight requirements. Does not have uncontrolled heart disease, asthma, or hypertension. Has not had an orthopedic injury, musculoskeletal problems, or orthopedic 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. Has had no seizures in the last year. Does not have poorly controlled diabetes. If less than 18 years of age and planning to scuba dive, does not have diabetes, asthma, or seizures. For high-adventure participants, I have reviewed with them the important supplemental risk advisory provided. Examiner’s Signature: Date: Provider printed name: Address: City: State: ZIP code: 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 60 166 61 172 62 178 63 183 64 189 Height (inches) Max. Weight 65 195 66 201 67 207 68 214 69 220 Maximum weight for height: 60 Height (inches) Max. Weight 166 61 172 62 178 63 183 64 189 Height (inches) 260 Max. Weight Height (inches) Max. Weight 70 226 71 233 72 239 73 246 74 252 Height (inches) Max. Weight 75 260 267 76 267 274 77 274 281 78 281 680-001 2014 Printing 295 79 and over 295Ten Mile River Scout Camps Greater New York Councils xxx.xxxxxxxxxxxx.xxx Individualized Medication Orders STANDARD OVER-THE-COUNTER/PRN MEDICATIONS CAMPER NAME: UNIT: CAMPER WEIGHT: lbs. DATE OF BIRTH: / / CAMP: HEALTHCARE PROVIDER NAME: LICENSE #: ADDRESS: HEALTHCARE PROVIDER SIGNATURE: I recognize that this is a two-page document DATE: / / HEALTHCARE PROVIDER STAMP: By order of the NYS Department of Health, this form is required for all campers under 18 years of age, and must be accompanied by a completed Annual BSA Health and Medical Record Form. The following medications are available in the camp Health Lodge and will be administered at the discretion of the camp Medical Officer, if approval is ordered by the Healthcare Provider below. Do not send these medications to camp; they are at the Health Lodge DRUG NAME ROUTE circle preferred formulation DOSAGE SCHEDULE PROVIDER ORDER check one COMMENTS BENADRYL (25 to 50 mg) PO (elixir, chewable tabs, pills) Per label instructions by age/weight Q 6 hr prn for allergic reaction (hives, insect bite) 🞎 YES 🞎 NO CEPACOL PO (lozenges) Per label instructions by age/weight Q 2 hr for sore throat (no > 4 doses in 24 hr and no fever) 🞎 YES 🞎 NO CHILDREN’S DIMETAPP COLD & ALLERGY PO (elixir, tabs) Per label instructions by age/weight Q 6-8 hr prn for nasal congestion/drainage 🞎 YES 🞎 NO IBUPROFEN (200 to 400 mg) PO (chewable tabs, suspension, tabs) Per label instructions by age/weight Q 6 hr prn for pain or fever > °F 🞎 YES 🞎 NO MYLANTA PO (chewable tabs) Per label instructions by age/weight TID prn for stomach upset 🞎 YES 🞎 NO CHILDREN’S PEPTO BISMOL PO (liquid, chewable tabs) Per label instructions by age/weight TID prn for stomach upset (no > 4 doses in 24 hr) 🞎 YES 🞎 NO ROBITUSSIN PO (syrup) Per label instructions by age/weight Q 4 hr prn for cough 🞎 YES 🞎 NO v. 1.4 revised 3/2011 Page 1 of 2 Individualized Medication Orders STANDARD OVER-THE-COUNTER/PRN MEDICATIONS CAMPER NAME: UNIT: CAMP: DRUG NAME ROUTE circle preferred formulation DOSAGE SCHEDULE PROVIDER ORDER check one COMMENTS TYLENOL PO (chewable tabs, elixir, tabs) Per label instructions by age/weight Q 4 hr prn for pain or fever > °F 🞎 YES 🞎 NO CALADRYL Topical Per label instructions by age/weight as directed for itches, bites, skin irritations, rashes 🞎 YES 🞎 NO BACITRACIN OINTMENT Topical Per label instructions by age/weight as directed for minor cuts and abrasions 🞎 YES 🞎 NO TINACTIN (or equivalent) Topical (liquid, powder) Per label instructions by age/weight as directed for athlete’s foot, jock itch, fungal rash 🞎 YES 🞎 NO The medications above are the only medications that are available in the camp Health Lodge. If additional over-the-counter medications are required, the camper’s parent/guardian must make arrangements to procure and send these medications to camp with the camper’s unit leader. The Healthcare Provider should list any such medications below. SELF-PROVIDED OVER-THE-COUNTER/PRN MEDICATIONS please strike out this section if not needed 🞎 YES 🞎 NO 🞎 YES 🞎 NO 🞎 YES 🞎 NO

Immunization. The following immunizations are recommended by the BSA. 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: 2014 Printing Part C: Pre-Participation Physical C This part must be completed by certified and licensed physicians (MD, DO), nurse practitioners, or physician assistants. High-adventure base participants: Expedition/crew No.: or staff position: Full name: DOB: ! ! You are being asked to certify that this individual has no contraindication for participation inside 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. Examiner: Please fill in the following information: Yes No Explain Medical restrictions to participate Yes No Allergies or Reactions Explain Yes No Allergies or Reactions Explain Medication Plants Food Insect bites/stings Height (inches): Weight (lbs.): BMI: Blood Pressure: / Pulse: Normal Abnormal Explain Abnormalities Eyes Ears/nose/ throat Lungs Heart Abdomen Genitalia/hernia Musculoskeletal Neurological Other Examiner’s Certification I certify that I have reviewed the health history and examined this person and find no contraindications for participation in a Scouting experience. This participant (with noted restrictions): True False Explain Meets height/weight requirements. Does not have uncontrolled heart disease, asthma, or hypertension. Has not had an orthopedic injury, musculoskeletal problems, or orthopedic 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. Has had no seizures in the last year. Does not have poorly controlled diabetes. If less than 18 years of age and planning to scuba dive, does not have diabetes, asthma, or seizures. For high-adventure participants, I have reviewed with them the important supplemental risk advisory provided. Examiner’s Signature: Date: Provider printed name: Address: City: State: ZIP code: 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 60 166 61 172 62 178 63 183 64 189 Height (inches) Max. Weight 65 195 66 201 67 207 68 214 69 220 Maximum weight for height: 60 Height (inches) Max. Weight 166 61 172 62 178 63 183 64 189 Height (inches) 260 Max. Weight Height (inches) Max. Weight 70 226 71 233 72 239 73 246 74 252 Height (inches) Max. Weight 75 260 267 76 267 274 77 274 281 78 281 680-001 2014 Printing 295 79 and over 295Summit Xxxxxxx Reserve High-Adventure Risk Advisory to Health-Care Providers and Parents Phone: 000-000-0000 Website: xxx.xxxxxxxxxxxxxxxxxxx.xxx The Summit Xxxxxxx 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 Experience. High-adventure activities at the Summit are variable and unique. All activities will require a certain level of fitness, and some activities can be very physically, mentally, and emotionally demanding. The program may include mountain biking, BMX biking, skateboarding, rock climbing, zip lines, challenge courses, shooting, archery, whitewater rafting, and

Immunization. The following immunizations are recommended by the BSA. 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: 2014 Printing Part C: Pre-Participation Physical C This part must be completed by certified and licensed physicians (MD, DO), nurse practitioners, or physician assistants. High-adventure base participants: Expedition/crew No.: or staff position: Full name: DOB: ! ! You are being asked to certify that this individual has no contraindication for participation inside 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. Examiner: Please fill in the following information: Yes No Explain Medical restrictions to participate Yes No Allergies or Reactions Explain Yes No Allergies or Reactions Explain Medication Plants Food Insect bites/stings Height (inches): Weight (lbs.): BMI: Blood Pressure: / Pulse: Normal Abnormal Explain Abnormalities Eyes Ears/nose/ throat Lungs Heart Abdomen Genitalia/hernia Musculoskeletal Neurological Other Examiner’s Certification I certify that I have reviewed the health history and examined this person and find no contraindications for participation in a Scouting experience. This participant (with noted restrictions): True False Explain Meets height/weight requirements. Does not have uncontrolled heart disease, asthma, or hypertension. Has not had an orthopedic injury, musculoskeletal problems, or orthopedic 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. Has had no seizures in the last year. Does not have poorly controlled diabetes. If less than 18 years of age and planning to scuba dive, does not have diabetes, asthma, or seizures. For high-adventure participants, I have reviewed with them the important supplemental risk advisory provided. Examiner’s Signature: Date: Provider printed name: Address: City: State: ZIP code: 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 60 166 61 172 62 178 63 183 64 189 Height (inches) Max. Weight 65 195 66 201 67 207 68 214 69 220 Height (inches) Max. Weight 70 226 71 233 72 239 73 246 74 252 Height (inches) Max. Weight 75 260 76 267 77 274 78 281 79 and over 295295 680-001 2014 Printing Northern Tier High-Adventure Risk Advisory to Health-Care Providers and Parents Phone: 000-000-0000 Website: xxx.xxxxx.xxx Northern Tier Experience. Participation at any of the BSA’s high-adventure bases or in any unit high-adventure backcountry/wilderness activities can be physically, mentally, and emotionally demanding. Each high-adventure base offers a unique experience that is not risk-free. Knowledgeable staff will instruct all participants in safety measures to be followed. Be prepared to listen to and carefully follow these safety measures and to accept responsibility for the health and safety of yourself and others. Northern Tier Requirements. Each person must be able to carry a 50- to 85-pound pack or canoe from a quarter- mile to 2 miles several times a day on rough, swampy, and rocky portages and paddle 10 to 15 miles per day, often against a headwind. The portage trails can be very muddy, slippery, and rocky, and those conditions can potentially lead to tripping and falling. All participants must wear boots that cover their ankles while on the trails. Climatic conditions can range from 30 to 100 degrees in summer/autumn and from -40 to 40 degrees in the winter. During the Okpik Experience, each person will walk, ski, or snowshoe along snow-covered trails or across frozen lakes, pulling loaded toboggans or sleds for up to 3 miles—or more if on a cross-country ski trek. Refer to the Northern Tier website for specific information. Be Prepared. While participating in Northern Tier’s canoeing and camping backcountry/wilderness areas, life jackets must be worn at all times when on the water. Crew members travel together at all times. Emergency communications via radio, and in more remote locations by satellite phone, are provided by Northern Tier. Radio communication and/or emergency evacuation can be hampered by weather, terrain, distance, time of day, equipment malfunction, and other factors, and are not a substitute for taking appropriate precautions and having adequate first-aid knowledge and equipment. Please call Northern Tier at 000-000-0000 if you have any questions. Seizures (Epilepsy). The seizure disorder must be well- controlled by 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 and will be based on the specific type of seizure and likely risks to the individual and/or other members of the crew. Diabetes Mellitus. Both the person with diabetes and one other person in the group need to be able to recognize signs of excessively high or low blood sugar and adjust the dose of insulin. An insulin-dependent person who was diagnosed or who has had a change in delivery system (e.g., insulin pump) in the last six months is advised not to participate. A person with diabetes who has had frequent hospitalizations or who has had problems with low blood sugar should not participate until better control of the diabetes has been achieved.

Immunization. The following immunizations are recommended by the BSA. 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: 2014 Printing Part C: Pre-Participation Physical C This part must be completed by certified and licensed physicians (MD, DO), nurse practitioners, or physician assistants. High-adventure base participants: Expedition/crew No.: or staff position: Full name: DOB: ! ! You are being asked to certify that this individual has no contraindication for participation inside 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. Examiner: Please fill in the following information: Yes No Explain Medical restrictions to participate Yes No Allergies or Reactions Explain Yes No Allergies or Reactions Explain Medication Plants Food Insect bites/stings Height (inches): Weight (lbs.): BMI: Blood Pressure: / Pulse: Normal Abnormal Explain Abnormalities Eyes ■ Ears/nose/ throat Lungs Heart Abdomen Genitalia/hernia Musculoskeletal Neurological Other Examiner’s Certification I certify that I have reviewed the health history and examined this person and find no contraindications for participation in a Scouting experience. This participant (with noted restrictions): True False Explain Meets height/weight requirements. Does not have uncontrolled heart disease, asthma, or hypertension. Has not had an orthopedic injury, musculoskeletal problems, or orthopedic 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. Has had no seizures in the last year. Does not have poorly controlled diabetes. If less than 18 years of age and planning to scuba dive, does not have diabetes, asthma, or seizures. For high-adventure participants, I have reviewed with them the important supplemental risk advisory provided. Examiner’s Signature: Date: Provider printed name: Address: City: State: ZIP code: 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 60 166 61 172 62 178 63 183 64 189 Height (inches) Max. Weight 65 195 66 201 67 207 68 214 69 220 Maximum weight for height: 60 Height (inches) Max. Weight 166 61 172 62 178 63 183 64 189 Height (inches) 260 Max. Weight Height (inches) Max. Weight 70 226 71 233 72 239 73 246 74 252 Height (inches) Max. Weight 75 260 267 76 267 274 77 274 281 78 281 79 and over 295680-001 2014 Printing

Immunization. The following immunizations are recommended by the BSA. 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: 2014 Printing Part C: Pre-Participation Physical C This part must be completed by certified and licensed physicians (MD, DO), nurse practitioners, or physician assistants. High-adventure base participants: Expedition/crew No.: or staff position: Full name: DOB: ! ! You are being asked to certify that this individual has no contraindication for participation inside 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. Examiner: Please fill in the following information: Yes No Explain Medical restrictions to participate Yes No Allergies or Reactions Explain Yes No Allergies or Reactions Explain Medication Plants Food Insect bites/stings Height (inches): Weight (lbs.): BMI: Blood Pressure: / Pulse: Normal Abnormal Explain Abnormalities Eyes Ears/nose/ throat Lungs Heart Abdomen Genitalia/hernia Musculoskeletal Neurological Other Examiner’s Certification I certify that I have reviewed the health history and examined this person and find no contraindications for participation in a Scouting experience. This participant (with noted restrictions): True False Explain Meets height/weight requirements. Does not have uncontrolled heart disease, asthma, or hypertension. Has not had an orthopedic injury, musculoskeletal problems, or orthopedic 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. Has had no seizures in the last year. Does not have poorly controlled diabetes. If less than 18 years of age and planning to scuba dive, does not have diabetes, asthma, or seizures. For high-adventure participants, I have reviewed with them the important supplemental risk advisory provided. Examiner’s Signature: Date: Provider printed name: Address: City: State: ZIP code: 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 60 166 61 172 62 178 63 183 64 189 Height (inches) Max. Weight 65 195 66 201 67 207 68 214 69 220 Maximum weight for height: 60 Height (inches) Max. Weight 166 61 172 62 178 63 183 64 189 Height (inches) 260 Max. Weight Height (inches) Max. Weight 70 226 71 233 72 239 73 246 74 252 Height (inches) Max. Weight 75 260 267 76 267 274 77 274 281 78 281 295 79 and over 295680-001 2014 Printing 0000 Xxxxxxxxxxx Xxxx Xxxx Xxxxxxxx, MN 55111 Fax: 000-000-0000 xxx.xxxxxxxxxxxx.xxx Permission to Participate in Shooting Sports for all Cub Scouts, Boy Scouts, Venturers and Explorers This permission form must be completed by the participant’s parent or legal guardian prior to any shooting activity. Name of Participant: I, (print your name) xxxxx my consent to Northern Star Council and to its representatives including Range Officers and Instructors and others serving in these positions to furnish my child with archery equipment, firearms and ammunition and provide instruction as to their safe and proper use. I further certify that I am the parent with full parental rights or the legal guardian of this child. I understand that this document will be kept and maintained by the Northern Star Council or its representatives including Range Officers and Instructors. I further understand that any modification of this form will result in its not being accepted by Northern Star Council, Range Officers and Instructors.

Immunization. The following immunizations are recommended by the BSA. 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: 2014 Printing Part C: Pre-Participation Physical C This part must be completed by certified and licensed physicians (MD, DO), nurse practitioners, or physician assistants. High-adventure base participants: Expedition/crew No.: or staff position: Full name: DOB: ! ! You are being asked to certify that this individual has no contraindication for participation inside 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. Examiner: Please fill in the following information: Yes No Explain Medical restrictions to participate Yes No Allergies or Reactions Explain Yes No Allergies or Reactions Explain Medication Plants Food Insect bites/stings Height (inches): Weight (lbs.): BMI: Blood Pressure: / Pulse: Normal Abnormal Explain Abnormalities Eyes Ears/nose/ throat Lungs Heart Abdomen Genitalia/hernia Musculoskeletal Neurological Other Examiner’s Certification I certify that I have reviewed the health history and examined this person and find no contraindications for participation in a Scouting experience. This participant (with noted restrictions): True False Explain Meets height/weight requirements. Does not have uncontrolled heart disease, asthma, or hypertension. Has not had an orthopedic injury, musculoskeletal problems, or orthopedic 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. Has had no seizures in the last year. Does not have poorly controlled diabetes. If less than 18 years of age and planning to scuba dive, does not have diabetes, asthma, or seizures. For high-adventure participants, I have reviewed with them the important supplemental risk advisory provided. Examiner’s Signature: Date: Provider printed name: Address: City: State: ZIP code: 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 60 166 61 172 62 178 63 183 64 189 Height (inches) Max. Weight 65 195 66 201 67 207 68 214 69 220 Maximum weight for height: 60 Height (inches) Max. Weight 166 61 172 62 178 63 183 64 189 Height (inches) 260 Max. Weight Height (inches) Max. Weight 70 226 71 233 72 239 73 246 74 252 Height (inches) Max. Weight 75 260 267 76 267 274 77 274 281 78 281 295 79 and over 295680-001 2014 Printing Florida Sea Base High-Adventure Risk Advisory to Health-Care Providers and Parents Phone: 000-000-0000 Website: xxx.xxxxxxxxxx.xxx Sea Base Experience. Each high-adventure base offers a unique experience that is not risk-free. Knowledgeable staff will instruct all participants in safety measures to be followed. Be prepared to listen to and carefully follow these safety measures and to accept responsibility for the health and safety of yourself and others. Climatic conditions at Florida Sea Base include temperatures ranging from 50 to 95 degrees, high humidity, heat indexes reaching to 110 degrees, and frequent, sometimes severe, afternoon thunderstorms. Activities include snorkeling, scuba diving, kayaking, canoeing, sailing, hiking, and others; all of these have potential for injury. Refer to the Sea Base website for specific information.

Immunization. The following immunizations are recommended by the BSA. 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: 2014 Printing Part C: Pre-Participation Physical C This part must be completed by certified and licensed physicians (MD, DO), nurse practitioners, or physician assistants. High-adventure base participants: Expedition/crew No.: or staff position: Full name: DOB: ! ! You are being asked to certify that this individual has no contraindication for participation inside 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. Examiner: Please fill in the following information: Yes No Explain Medical restrictions to participate Yes No Allergies or Reactions Explain Yes No Allergies or Reactions Explain Medication Plants Food Insect bites/stings Height (inches): Weight (lbs.): BMI: Blood Pressure: / Pulse: Normal Abnormal Explain Abnormalities Eyes Ears/nose/ throat Lungs Heart Abdomen Genitalia/hernia Musculoskeletal Neurological Other Examiner’s Certification I certify that I have reviewed the health history and examined this person and find no contraindications for participation in a Scouting experience. This participant (with noted restrictions): True False Explain Meets height/weight requirements. Does not have uncontrolled heart disease, asthma, or hypertension. Has not had an orthopedic injury, musculoskeletal problems, or orthopedic 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. Has had no seizures in the last year. Does not have poorly controlled diabetes. If less than 18 years of age and planning to scuba dive, does not have diabetes, asthma, or seizures. For high-adventure participants, I have reviewed with them the important supplemental risk advisory provided. Examiner’s Signature: Date: Provider printed name: Address: City: State: ZIP code: 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 60 166 61 172 62 178 63 183 64 189 Height (inches) Max. Weight 65 195 66 201 67 207 68 214 69 220 Height (inches) Max. Weight 70 226 71 233 72 239 73 246 74 252 Height (inches) Max. Weight 75 260 76 267 77 274 78 281 79 and over 295295 680-001 2014 Printing REQUIRED FOR CUB DAY CAMP, CUB RESIDENT CAMP, & BOY SCOUT RESIDENT CAMP I hereby give permission for my son/daughter (please print youth’s name) to carry and use sunscreen and/or insect repellent that I have provided at camp and throughout the day. If my child needs help re-applying either sunscreen or insect repellent, I give permission for camp staff to provide my child with assistance if he/she requests it. Parent or Guardian Signature:

Immunization. The following immunizations are recommended by the BSA. 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: 2014 Printing Part C: Pre-Participation Physical C This part must be completed by certified and licensed physicians (MD, DO), nurse practitioners, or physician assistants. High-adventure base participants: Expedition/crew No.: or staff position: Full name: DOB: ! ! You are being asked to certify that this individual has no contraindication for participation inside 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. Examiner: Please fill in the following information: Yes No Explain Medical restrictions to participate Yes No Allergies or Reactions Explain Yes No Allergies or Reactions Explain Medication Plants Food Insect bites/stings Height (inches): Weight (lbs.): BMI: Blood Pressure: / Pulse: Normal Abnormal Explain Abnormalities Eyes Ears/nose/ throat Lungs Heart Abdomen Genitalia/hernia Musculoskeletal Neurological Other Examiner’s Certification I certify that I have reviewed the health history and examined this person and find no contraindications for participation in a Scouting experience. This participant (with noted restrictions): True False Explain Meets height/weight requirements. Does not have uncontrolled heart disease, asthma, or hypertension. Has not had an orthopedic injury, musculoskeletal problems, or orthopedic 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. Has had no seizures in the last year. Does not have poorly controlled diabetes. If less than 18 years of age and planning to scuba dive, does not have diabetes, asthma, or seizures. For high-adventure participants, I have reviewed with them the important supplemental risk advisory provided. Examiner’s Signature: Date: Provider printed name: Address: City: State: ZIP code: 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 60 166 61 172 62 178 63 183 64 189 Height (inches) Max. Weight 65 195 66 201 67 207 68 214 69 220 Height (inches) Max. Weight 70 226 71 233 72 239 73 246 74 252 Height (inches) Max. Weight 75 260 76 267 77 274 78 281 79 and over 295295 Florida Sea Base High-Adventure Risk Advisory to Health-Care Providers and Parents Phone: 000-000-0000 Website: xxx.xxxxxxxxxx.xxx Sea Base Experience. Each high-adventure base offers a unique experience that is not risk-free. Knowledgeable staff will instruct all participants in safety measures to be followed. Be prepared to listen to and carefully follow these safety measures and to accept responsibility for the health and safety of yourself and others. Climatic conditions at Florida Sea Base include temperatures ranging from 50 to 95 degrees, high humidity, heat indexes reaching to 110 degrees, and frequent, sometimes severe, afternoon thunderstorms. Activities include snorkeling, scuba diving, kayaking, canoeing, sailing, hiking, and others; all of these have potential for injury. Refer to the Sea Base website for specific information.

Immunization. The following immunizations are recommended by the BSA. 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: 2014 Printing Part C: Pre-Participation Physical C This part must be completed by certified and licensed physicians (MD, DO), nurse practitioners, or physician assistants. High-adventure base participants: Expedition/crew No.: or staff position: Full name: DOB: ! ! You are being asked to certify that this individual has no contraindication for participation inside 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. Examiner: Please fill in the following information: Yes No Explain Medical restrictions to participate Yes No Allergies or Reactions Explain Yes No Allergies or Reactions Explain Medication Plants Food Insect bites/stings Height (inches): Weight (lbs.): BMI: Blood Pressure: / Pulse: Normal Abnormal Explain Abnormalities Eyes Ears/nose/ throat Lungs Heart Abdomen Genitalia/hernia Musculoskeletal Neurological Other Examiner’s Certification I certify that I have reviewed the health history and examined this person and find no contraindications for participation in a Scouting experience. This participant (with noted restrictions): True False Explain Meets height/weight requirements. Does not have uncontrolled heart disease, asthma, or hypertension. Has not had an orthopedic injury, musculoskeletal problems, or orthopedic 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. Has had no seizures in the last year. Does not have poorly controlled diabetes. If less than 18 years of age and planning to scuba dive, does not have diabetes, asthma, or seizures. For high-adventure participants, I have reviewed with them the important supplemental risk advisory provided. Examiner’s Signature: Date: Provider printed name: Address: City: State: ZIP code: 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 60 166 61 172 62 178 63 183 64 189 Height (inches) Max. Weight 65 195 66 201 67 207 68 214 69 220 Maximum weight for height: 60 Height (inches) Max. Weight 166 61 172 62 178 63 183 64 189 Height (inches) 260 Max. Weight Height (inches) Max. Weight 70 226 71 233 72 239 73 246 74 252 Height (inches) Max. Weight 75 260 267 76 267 274 77 274 281 78 281 295 79 and over 295680-001 2014 Printing Summit Xxxxxxx Reserve High-Adventure Risk Advisory to Health-Care Providers and Parents Phone: 000-000-0000 Website: xxx.xxxxxxxxxxxxxxxxxxx.xxx The Summit Xxxxxxx 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 Experience. High-adventure activities at the Summit are variable and unique. All activities will require a certain level of fitness, and some activities can be very physically, mentally, and emotionally demanding. The program may include mountain biking, BMX biking, skateboarding, rock climbing, zip lines, challenge courses, shooting, archery, whitewater rafting, and kayaking. Depending on the high-adventure programs you select, you will need to arrive at the Summit physically prepared to participate in those activities. A body mass index (BMI) of 32 or less is required to participate in all of the high-adventure activities at the Summit. Those with BMIs of 32 to 40 will require additional documentation from their physicians stating that they are fit to participate in the high-adventure activities for which they have registered. No participant with a BMI greater than 40 will be allowed at the Summit and will be sent home at their own expense. In addition, those intending to visit the Summit should be aware of the conditions there: The average temperature at the Summit from June through August is 60 to 80 degrees, and the humidity averages 70 to 75 percent. Also, the terrain at the Summit is very hilly, and the layout requires considerable walking and effort. Participants will walk several miles a day to get to activity areas. Be prepared! It is recommended that every participant review information about the Summit Xxxxxxx Reserve at xxx.xxxxxxxxxx.xxx 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@ xxxxxxxx.xxx, or you may call 000-000-0000.

Immunization. The following immunizations are recommended by the BSA. 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: 2014 Printing Part C: Pre-Participation Physical C This part must be completed by certified and licensed physicians (MD, DO), nurse practitioners, or physician assistants. High-adventure base participants: Expedition/crew No.: or staff position: Full name: DOB: ! ! You are being asked to certify that this individual has no contraindication for participation inside 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. Examiner: Please fill in the following information: Yes No Explain Medical restrictions to participate Yes No Allergies or Reactions Explain Yes No Allergies or Reactions Explain Medication Plants Food Insect bites/stings Height (inches): Weight (lbs.): BMI: Blood Pressure: / Pulse: Normal Abnormal Explain Abnormalities Eyes Ears/nose/ throat Lungs Heart Abdomen Genitalia/hernia Musculoskeletal Neurological Other Examiner’s Certification I certify that I have reviewed the health history and examined this person and find no contraindications for participation in a Scouting experience. This participant (with noted restrictions): True False Explain Meets height/weight requirements. Does not have uncontrolled heart disease, asthma, or hypertension. Has not had an orthopedic injury, musculoskeletal problems, or orthopedic 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. Has had no seizures in the last year. Does not have poorly controlled diabetes. If less than 18 years of age and planning to scuba dive, does not have diabetes, asthma, or seizures. For high-adventure participants, I have reviewed with them the important supplemental risk advisory provided. Examiner’s Signature: Date: Provider printed name: Address: City: State: ZIP code: 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 60 166 61 172 62 178 63 183 64 189 Height (inches) Max. Weight 65 195 66 201 67 207 68 214 69 220 Height (inches) Max. Weight 70 226 71 233 72 239 73 246 74 252 Height (inches) Max. Weight 75 260 76 267 77 274 78 281 79 and over 295295 680-001 2014 Printing Medical Insurance Information of Scout

Immunization. The following immunizations are recommended by the BSA. 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 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: 2014 Printing Part CB: Pre-Participation Physical C This part must be completed by certified and licensed physicians (MD, DO), nurse practitioners, or physician assistants. General Information/Health History B High-adventure base participants: Expedition/crew No.: or staff position: Full name: DOB: ! ! You are being asked to certify that this individual has no contraindication for participation inside 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. ExaminerAge: Please fill in the following informationGender: Yes No Explain Medical restrictions to participate Yes No Allergies or Reactions Explain Yes No Allergies or Reactions Explain Medication Plants Food Insect bites/stings Height (inches): Weight (lbs.): BMI: Blood Pressure: / Pulse: Normal Abnormal Explain Abnormalities Eyes Ears/nose/ throat Lungs Heart Abdomen Genitalia/hernia Musculoskeletal Neurological Other Examiner’s Certification I certify that I have reviewed the health history and examined this person and find no contraindications for participation in a Scouting experience. This participant (with noted restrictions): True False Explain Meets height/weight requirements. Does not have uncontrolled heart disease, asthma, or hypertension. Has not had an orthopedic injury, musculoskeletal problems, or orthopedic 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. Has had no seizures in the last year. Does not have poorly controlled diabetes. If less than 18 years of age and planning to scuba dive, does not have diabetes, asthma, or seizures. For high-adventure participants, I have reviewed with them the important supplemental risk advisory provided. Examiner’s Signature: Date: Provider printed name: Address: City: State: ZIP code: Office Telephone: Unit leader: Mobile phone: HeightCouncil Name/Weight Restrictions No.: Unit No.: Health/Accident Insurance Company: Policy No.: ! ! Please attach a photocopy of both sides of the insurance card. If you exceed do not have medical insurance, enter “none” above. In case of emergency, notify the maximum person below: Name: Relationship: Address: Home phone: Other phone: Alternate contact name: Xxxxxxxxx’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: 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 Last attack date: Lung/respiratory disease COPD Ear/eyes/nose/sinus problems Muscular/skeletal condition/muscle or bone issues Head injury/concussion Altitude sickness Psychiatric/psychological or emotional difficulties Behavioral/neurological disorders Blood disorders/sickle cell disease Fainting spells and dizziness Kidney disease Seizures Last seizure date: Abdominal/stomach/digestive problems Thyroid disease Excessive fatigue Obstructive sleep apnea/sleep disorders CPAP: Yes £ No £ List all surgeries and hospitalizations Last surgery date: List any other medical conditions not covered above 680-001 2014 Printing Appendix G ANNUAL HEALTH AND MEDICAL RECORD INFORMATION AND FAQS Annual Health and Medical Record Information and FAQs Personal Health and the Annual Health and Medical Record Risk Factors. Scouting activities can be physically and mentally demanding. Listed below are some of the risk factors that have been known to become issues during outdoor adventures. Find the current Annual Health and Medical Record by using this QR code or by visiting xxxx://xxx.xxxxxxxx.xxx/ HealthandSafety/ahmr.aspx. The Scouting adventure, camping trips, high- adventure excursions, and having fun are important to everyone in Scouting—and so are your safety and well-being. • Exessive body weight (obesity) • Cardiac or cardiovascular disease • Hypertension (high blood pressure) • Diabetes mellitus • Seizures • Asthma • Sleep apnea • Allergies or anaphylaxsis • Musculoskeletal injuries • Psychological and emotional difficulties Completing the Annual Health and Medical Record is the first step in making sure you have a great Scouting experience. So what do you need? All Scouting Events. All participants in all Scouting activities complete Part A and Part B. Give the completed forms to your unit leader. This applies to all activities, day camps, local tours, and weekend camping trips less than 72 hours. Update at least annually. Part A is an informed consent, release agreement, and authorization that needs to be signed by every participant (or a parent and/or legal guardian for height all youth under 18). Part B is general information and a health history. Going to Camp? A pre-participation physical is needed for resident, tour, or trek camps or for a Scouting event of more than 72 hours, such as explained in Wood Badge and NYLT. The exam needs to be completed by a certified and licensed physician (MD, DO), nurse practitioner, or physician assistant. If your camp has provided you with any supplemental risk information, or if your plans include attending one of the following chart and your planned four national high-adventure activity will take bases, share the venue’s risk advisory with your medical provider when you more than 30 minutes away are having your physical exam. Part C is your pre-participation physical certification. Planning a High-Adventure Trip? Each of the four national high-adventure bases has provided a supplemental risk advisory that explains in greater detail some of the risks inherent in that program. All high-adventure participants must read and share this information with their medical providers during their pre-participation physicals. Additional information regarding high- adventure activities may be obtained directly from an emergency vehicle/accessible roadway, you may not be allowed to participate. Maximum weight for height: Height (inches) Max. Weight 60 166 61 172 62 178 63 183 64 189 Height (inches) Max. Weight 65 195 66 201 67 207 68 214 69 220 Height (inches) Max. Weight 70 226 71 233 72 239 73 246 74 252 Height (inches) Max. Weight 75 260 76 267 77 274 78 281 79 and over 295the venue or your local council.

Immunization. The following immunizations are recommended by the BSA. 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: 2014 Printing Part C: Pre-Participation Physical C Required for all participants of all full-week, sleep-away programs. This part must be completed by certified and licensed physicians (MD, DO), nurse practitioners, or physician assistants. High-adventure base participants: Expedition/crew No.: or staff position: Full name: DOB: ! ! You are being asked to certify that this individual has no contraindication for participation inside 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. Examiner: Please fill in the following information: Yes No Explain Medical restrictions to participate Yes No Allergies or Reactions Explain Yes No Allergies or Reactions Explain Medication Plants Food Insect bites/stings Height (inches): Weight (lbs.): BMI: Blood Pressure: / Pulse: Normal Abnormal Explain Abnormalities Eyes Ears/nose/ throat Lungs Heart Abdomen Genitalia/hernia Musculoskeletal Neurological Other Examiner’s Certification I certify that I have reviewed the health history and examined this person and find no contraindications for participation in a Scouting experience. This participant (with noted restrictions): True False Explain Meets height/weight requirements. Does not have uncontrolled heart disease, asthma, or hypertension. Has not had an orthopedic injury, musculoskeletal problems, or orthopedic 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. Has had no seizures in the last year. Does not have poorly controlled diabetes. If less than 18 years of age and planning to scuba dive, does not have diabetes, asthma, or seizures. For high-adventure participants, I have reviewed with them the important supplemental risk advisory provided. Examiner’s Signature: Date: Provider printed name: Address: City: State: ZIP code: 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 60 166 61 172 62 178 63 183 64 189 Height (inches) Max. Weight 65 195 66 201 67 207 68 214 69 220 Height (inches) Max. Weight 70 226 71 233 72 239 73 246 74 252 Height (inches) Max. Weight 75 260 76 267 77 274 78 281 79 and over 295295 2014 Printing Part D: Treasure Valley Scout Reservation Supplement D Required for all youth participants of all programs. Scout/Child's name : Unit/Group : DOB: Shooting Sports Camp Program/Week Attending: Compliance to State Law : Authorized use of firearms by a minor. The Mohegan Council adheres to all applicable laws and operates under the governance of BSA National Standards as well as MA State Health Code. As a part of the Boy Scout program the council operates several safe shooting sports ranges for scouts to participate in BB shooting (Cub Scouts), rifle shooting & shotgun (Boy Scouts), and archery (Cub Scouts and Boy Scouts). In order to meet the Mass General Laws Chapter 140 section 130 the Council requires parental permission to participate in such activities. Mass General Laws Chapter 140, Section 130 stipulates the following: Furnishing Child 15 or older with Rifle, Shotgun and Ammunition “Nothing in this section shall be construed to prohibit an instructor from furnishing rifles or shotguns or ammunition to pupils; provided however that said instructor has the consent of a parent or guardian of a pupil under the age of 18.” The pupil must be under the direct supervision of a person (the range instructor) holding a valid Firearms Identification Card or a License to Carry Firearms. ! I hereby AUTHORIZE my child, named above, to participate in all events during summer camp including (if age appropriate) use of the shooting sports program areas (for rifle and shotgun under supervision of an FID instructor). I DO NOT AUTHORIZE my child, named above, to participate in shooting sports activities. However, my child is authorized to participate in all other events and activities of the camp. Over the Counter Medications The following over the counter medications will be available through the health officer if a Scout becomes ill during camp. Please check the medications your child may be given if needed. Medicine will be administered per package instructions. Please send your child’s own supply of over the counter medicine (in the original container) if they are a normal routine or taken daily. NOTE: Failure to complete this section or to authorize any OTC Medication can result in a uncomfortable experience at camp. If you have any questions regarding administration of medications, please contact camp personnel. Check all that are authorized: Acetaminophen (Tylenol) Pepto Bismol Bug Spray Sun Burn Cream (Aloe) Ibuprofen (Motrin) Decongestant After Bite Calamine Lotion Benadryl/Antihistamine Antacid Eye Drops Antibiotic Ointment Anti-Diarrhea Swimmer's Ear Sun Block Informed Consent & Release I consent that the prior provided information is accurate and true. I acknowledge that I am allowing my Scout/Child to participate at summer camp entirely upon my own initiative, risk and responsibility. I further, in consideration of the permission extended to my child to attend summer camp, do hereby for myself, my spouse, my child, my heirs, executors, and administrators, remiss, release, and forever discharge the Camp Administration, staff, and volunteers of Treasure Valley Scout Reservation, as well as the Mohegan Council, the Boy Scouts of America, its officers, members, as well as all other participants and sponsors of said summer camp, acting officially or otherwise, from all claims, demands, actions or causes of action of any kind including death of my child or any injury to my child or loss or damage to property which may occur from any cause during summer camp. Parent/Guardian of Scout/Child signature: Date: v1.1