Register by April 15th and receive a free shirt!

Cub Leader/Parent, Holiday Roads at Akela The Camp Akela staff is so excited to invite you and your Scouts to our Akela Staycation, inspired by our favorite things to do when road tripping across the country! A session won’t be complete without a trip to Camp Akela’s Aeronautic Space Administration (CAASA) where Premier Programs you will get to build and launch your own rockets and moon rock climb, making sand art at the CAASA’s Training center at Fort Pella Tew Cabin Beaches and building a box to keep all of your memories safe. Don’t fret though, CAASA’s (Camp Akela Aeronautics and Space you’ll still get to do all of your camp favorites with wild west shooting with BB guns and Administration) Training Center at Fort Pella is ready for archery,fishing at great Lake Fisher and of course taking a dip in the pool to cool off! your aeronautic experience with Moon Rock Climbing and This summer we have made some changes to camp arrival and departure times so please be sure building your own rocket to launch at the Cope Canaveral to look at your schedule closely. We strive to create a memorable camping experience for you Field. and your Scouts, while also contributing to rank advancement and instilling the values of the Scout Oath and Law along the way. Experience at ALL Camps this summer! This guide contains all of the information you need to register and plan for the best experience for your Scout(s) this summer. Please read through the information provided and share with Sand in a Bottle! other parents and leaders. Feel free to contact the Maytag Scout Center with any questions Traveling to the Tew Cabin Beaches about your camp experience at Camp Akela. Create a lovely bottle of sand art with the many different colored sands available. Take home a Thank you for choosing to embark on this adventure and to make memories with your wonderful momento! Scout that will last a lifetime! Experience at ALL Camps this summer! Thank you,

Tabby Robinson Holiday Keepsakes Box Camp Director Even a skilled traveler wants to keep Camp Akela wonderful memories safe. What better way than to make a keepsake box for those memories?

Experience at Bears, Webelos and Pack Resident Camp Contact Information Send Your Camper Mail! Camps! Camp HQ Telephone (only June 5 through July 18, 2020) allow 3 days minimum for delivery 515-438-2351 (Scout’s Name) Council Office Telephone (M-F 8:30am– 5:00pm) Rafting Adventure 515-266-2135 (Pack Number)-Camp Akela Venture down to Lake Fisher and be ready to Council General Email M i t i g w a S c o u t R e s e r v a t i o n get wet! Practice your rafting skills on Lake [email protected] 1820 Magnolia Road Fisher and learn how to work as a team. Council Web Address: https://scoutingiowa.org/ Woodward, IA 50276 Experience ONLY at Webelos camp! Camp Akela Email (only June 5 through July 18, 2020): [email protected]

2 3 Overnighter Bear Camp Check In at 9 am Check In at 6 pm Check Out at 9am Check Out at 9 am Day 1 Day 2 Day 3 Day 1 Day 2 Cub Scout Overnighter is a 24-hour jam- 9am Flags Bear Camp is slightly longer than a Cub Scout packed fun-filled Camp Akela experience. Continental Overnighter and is specifically designed for Check In Flags 9am 9am This shortened camp is open to all ages but Breakfast Bear Scouts. With so many fun activities, the Welcome Tour Continental Check out and Campsite Set Up Breakfast most recommended for Tigers and Wolves. Cub Scouts will have no idea that they are collect health forms Check out and Programs offered this year include: working on rank advancement. Some favorite Depart for home collect health programming from past years will be offered •Swimming Flags forms •BB guns, Archery, & Wrist Rockets again, including: Depart for home Breakfast •Pedal Cars (MASCAR) •Swimming Leaders Meeting Program Special to this summer Area 1 •BB guns, Archery, & Wrist Rockets Program Area 1 •CAASA (Camp Akela Aeronautics and Program •Pedal Cars (MASCAR) Space Administration) Rocket build and Area 2 •Fishing (The Great Lake Fisher) Lunch launch. Lunch Special to this summer Program Area 2 •Beach Sand Art Program •CAASA (Camp Akela Aeronautics Area 3 Program Area 3 and Space Administration) Rocket build Program and launch. Area 4 Program Area 4 •Wild West (Roping And Branding) Open Areas Flags •Beach Sand Art Break •Keepsake boxes Dinner Flags

Open Time 6:00pm Dinner Check In Campfire Welcome Tour Unit/Campsite Set up Time Campsite 10pm Lights Out Leaders Open Areas *Schedule subject to change. Please refer to the Meeting schedule provided at check in* Smores by Camp Ake- the campfire la Campfire Lights Out Lights Out

*Schedule subject to change. Please refer to the schedule provided at check in* 4 5 Webelos Camp Adventures Check In at 3 pm Check Out at 9 am Adventure 1 (Morning): Day 1 Day 2 Day 3 Day 4 1st Responder Webelos Camp is a 4 day A Scout is prepared. Learn how to respond to emergencies in a safe and effective manner. summer camp experience for Participants will work to earn 1st Responder: 1-8. Adventures in Engineering Flags Flags Flags Webelos and Arrow of Light In this adventure, you will discover how different types of engineers work to solve problems. Design and build Scouts. Campers will have the using your own ideas and engineering skills. Breakfast Breakfast Breakfast Participants will work to earn all requirements. opportunity to make lifelong Webelos Walkabout/Castaway Adventure Program memories doing their favorite Hiking is something you need to always plan for. Plan and prepare for a hike, and join in on the hike around 1 Area 5 programs from past summers Mitigwa. Lost in the woods? Separated from your group? Increase your chances of survival and learn survival Program Program skills before you need them! and new ones special to this Participants will work to earn Webelos Walkabout requirements: 1, 2, & 3 Area 1 Area 6 summer Participants will work to earn Castaway requirements: 1b, 1c, 2a, 2b, 2c, & 2d. Lunch Break Campsite Outdoor Adventurer/Into the Woods Clean up •Swimming Think you are ready to set up camp anywhere? Practice your camping skills and brush up on your knowledge Program Lunch 9am •Shooting Sports about the earth around you! Area 2 Depart • Rafts Participants will work to earn Outdoor Adventurer 1,2,3,4, & 5. from • Participants will work to earn Into the Woods 1,2,3,5 & 6. Camp 3-5pm Check In Program Program Set up Campsite Area 3 Area 7 Leaders Meeting Program Program •Adventures Adventure 2 (Afternoon): Choose 1 adventure per time Aquanaut Area 4 Area 8 Get trained on safe swimming and boating skills in Aquanaut. You will work on passing beginner and BSA Break Adventure 2 slot while registering for camp swimmer’s tests and learn how to respond to water emergencies. This adventure prepares you for more online. challenging Scout aquatic activities. Flags Flags Flags See adventure options and Participants will work to earn requirements: 1, 2, 3, 4, 5, 7, & 8. Art Explosion! Dinner Dinner Dinner descriptions on the next page. In this adventure, your artistic abilities will be challenged. From painting to sculpting, you will enjoy being creative at camp! Evening activities Open Areas Open Areas Participants will work to earn requirements:2, 3b, 3c, & 3d Webelos Walkabout/Castaway Campsite/Pack Campfire Campsite/ Hiking is something you need to always plan for. Plan and prepare for a hike, and join in on the hike around time Pack time Mitigwa. Lost in the woods? Separated from your group? Increase your chances of survival and learn survival Lights Out Lights Out Lights Out skills before you need them! Participants will work to earn Webelos Walkabout requirements: 1, 2, 3. Participants will work to earn Castaway requirements: 1b, 1c, 2a, 2b, 2c & 2d, Cast Iron Chef *Schedule subject to change. Please refer to the schedule Cook your way into great camp food, by learning about balanced meals, how to start a fire and learn to use provided at check in* different implements and methods of cooking. Participants will work to earn Cast Iron Chef requirements: 1, 2, 3. 6 7 Before You Leave Home Adult Leadership: Camp Akela requires adult supervision for the Scouts attending camp. ALL Pack Resident adults must have youth protection training before arriving at camp. Please provide proper Check In at 3pm documentation when checking in. The ratio for youth/adult participation is set based on the Check Out at 9am session you attend. Cub Overnighter: 1 youth to 1 parent/guardian. Bear: 6 youth to 1 adult. Minimum of 2 adults Webelos: 8 youth to 1 adult. Minimum of 2 adults Day 1 Day 2 Day 3 Day 4 Pack Resident camp is a 4 Pack Resident: 6 youth to 1 adult. Exception: Tigers must be accompanied by their parent/guardian day experience for the whole the entire length of camp. Minimum of 2 adults pack to enjoy! Programming Heath Forms: A BSA Annual Health and Medical Record with parts A, B, is required for all Flags Flags Flags will cover some requirements campers (youth and adult). These forms should be brought with you and turned in at registration from every age group but most the first day of your camp. A copy of the BSA Annual Health and Medical Record may be found Breakfast Breakfast Breakfast importantly be packed with fun in the appendix or at https://filestore.scouting.org/filestore/HealthSafety/pdf/680-001_AB.pdf. Health forms may NOT be emailed. Should a person need to send their health form to camp they Program Program for the Scouts to enjoy together. may use the camp fax number: 515-438-4277. Area 1 Area 5 Some of the programs that will Program Program be offered include: Area 2 Area 6 •Swimming ****Masks are required in all buildings and when social distancing is not possible.**** Lunch Break Campsite •BB guns, Archery, & Recommended Equipment List: Clean up Wrist Rockets Program Lunch 9am __ swimsuit __ uniform shirt __ sunscreen •Pedal Cars Area 3 Depart __ pants/shorts/slacks __ jacket __ watch from •Fishing __ underwear & socks __ sweater __ lawn chairs Camp Special to this summer __ water bottle __ mosquito repellent (non-aerosol) __ small backpack Program Program •CAASA (Camp Akela __ rain gear __ towels __ cot Area 4 Area 7 Aeronautics and S p a c e __ sleeping bag __ spending money for Trading Post __ Pajamas __ pillow __ Cub Scout handbook __ camera 3-5pm Check In Open Areas Program Administration) Set up Campsite Area 8 __ flashlight __ Cub Scout knife (whittling chip required) •Wild West (Roping And Leaders Meeting Break Program __ closed toed shoes Area 9 Branding) __ snacks (if desired, but also can be purchased at Trading Post) Flags Flags Flags •Beach Sand Art __ tent •Keepsake boxes Dinner Dinner Dinner Being prepared is vital to a great camping experience but bringing more than necessary may weigh down your check in and check out process. Please be mindful of bringing only Open Areas Break the necessities to your session at Camp. Camp Akela is not responsible for broken, lost, or stolen items. Valuables should not be brought Campsite/Pack Campfire Campsite/ to camp along with: time Pack time • Open toed shoes • Electronics • Personal Firearms • Pets *Schedule subject to change. Please refer to the schedule • Fireworks • Bicycles provided at check in* • Alcohol/Illegal Drugs • Aerosol bug spray 8 9 Check In/Check Out Check In We will be staggering the check in times for our camps. The registered leader for your unit will receive an email with your campsite assignment and the time slot for you to arrive at camp about 2 weeks before your session. To maintain the safety of our camp, cars are not permitted to drive past the parking lot unless previously given permission from the director. Trailers will be provided for each campsite to put their gear on and will be taken to the campsite when the trailer is full. It is not recommended to bring a pack trailer for your short stay at Camp Akela but Camp Facilities if necessary, your trailer can be parked in the camp parking lot so you can access Campsites: Camp Akela has four campsites. Your pack will receive notification your gear as needed. Please notify camp adminstration if you are bringing a trailer of your assigned campsite via the email address of the person who registered the so we can better serve you. group. Email notifications will be sent out approximately 2 weeks prior to your Only 1 adult leader needs to check in your unit, the rest of your pack or den will camp. You and your pack will be sharing the campsite with other campers. Please collect their gear and load up trailers or rickshaws. Gear on trailers will be brought remember the Scout Oath and Law. to the campsites once full. During camp setup, there will be a leader’s meeting to help answer any questions and review expectations and procedures at camp. The Our rustic campsites provide a picnic shelter with several picnic tables and a fire adult leader checking in your unit should have BSA health forms and photocopies ring. Do not bring firewood from home as disease and pests can spread. of health insurance cards for all campers, along with current Youth Protection certificates for alladult leaders and parents that will be staying. Shower and Bath Facilities: Adult showers are located in Bear Creek Lodge and at the Frankel Pool Shower House. Youth showers are located only at the Frankel Pool Shower House. There are flushable bathroom facilities at both locations. Check Out Check out times are designated on the schedule pages. Before leaving camp make Bear Creek Lodge/ Trading Post: Akela Director’s office is located in Bear sure 1 adult leader from your pack comes to retrieve the entire pack’s health forms Creek Lodge. For any emergencies, concerns, or questions, please stop by. Camp and patches from Bear Creek. All health forms left at the end of a session will be Akela’s Trading Post is also located in Bear Creek and has a selection of souvenirs, shredded. refreshments, craft materials, and much more. Cash and credit cards are accepted. Hours are posted at camp. We hope that all of our campers are able to stay for the whole session but understand if early departure is necessary. Only designated adults may take a youth Medical Care: A health officer serves as a regular member of camp staff and off camp property and must set up a time with the Camp Director to check out serves the Mitigwa Scout Reservation. In the event of serious accidents, illness, or before leaving property. hospitalization, parents are contacted. If you are bringing medicine to camp please review the “medications section” on page 17. Please plan to be leaving property at the designated check out time.

10 11 Emergency Procedures Preventative Safety Policies Accident or Injury: All Mitigwa Scout Reservation Staff are First Aid trained Knife Safety: Following National Policy-only Scouts that have earned their and a Health Officer serves as a regular member of Camp Staff. If an injury is life Whittling Chip will be allowed to carry a pocketknife around camp. Please ensure threatening and needs emergency services, please call 911 and inform the your Scouts know knives are not toys. Pocketknives are available for purchase at staff and administration as soon as possible so they can prepare and direct staff as the Trading Post. Leaders and parents, please make sure you talk with your Scout needed. about permission to buy pocketknives before coming to Camp. Extreme Heat and/or Humidity: In the event of the temperature and/or humidity reaching an extreme level which may endanger health, all events will Heat Stroke/Exhaustion: The best way to prevent heat related sickness is be discontinued until further notice. The person in charge will determine if the to ensure everyone is hydrated and wearing appropriate summer attire and sun emergency exists. Campers will be expected to rest during this time period. protection. Light colored clothing, hats, sunglasses and sun block are all ways to Child Endangerment: All camp staff members have been trained in youth protect your Scouts and yourself from the sun along with making sure everyone has protection policies for handling this situation. Evidence or suspicion of child abuse/ a water bottle with them at all times. Please remember open toed shoes are not neglect should be reported to the Reservation Director. If an adult is attempting to allowed outside of the pool at any time. remove a youth from camp, please notify the nearest camp staff member who will then contact Camp Administration. Youth Protection: Ensuring our Scouts are safe is our number one priority. Missing Scout: Notify Camp HQ immediately. Every adult on property must have Youth Protection certification and are all Fire: Implement the Camp Fireguard Plan and notify Camp HQ. accountable for ensuring those policies are followed. In an event that this is in High Winds/Tornadoes/Severe Storms: Unit leaders will be notified by question, please contact the Admin team immediately. Camp has zero tolerance Camp Administration on the current situation and weather plan for leaders to for any hindrance of these policies and those in question will be asked to leave the follow. All Aquatics facilities will close if severe weather and/or lightning are property and reported to the Scout Executive. evident. Per Hazardous Weather Training, Aquatics must shut down as soon as lightning or thunder occur within sight or sound and remain closed until 30 minutes Missing Scout: Leaders are accountable for the location of their Scouts at all after the last occurrence. times. Scouts are to follow the buddy system and travel with a buddy from their den at all times. They should inform their leaders where they are going and what their During an emergency mobilization, no individuals are to leave camp property plans are. unless given permission from the Reservation Director or Associate Reservation Director. This is for the safety of our campers. Fire Safety: Do NOT use liquid fuels to start fires. Gas lanterns may be used under adult supervision. All liquid fuels must be locked in proper storage according to National Camp Standards. National Camp Standards prohibit the use of flames in tents at any time. All tents will be marked with “No Flames in Tents” either on the tent or with a sign near the tent. Never leave a fire unattended.Always put out fires with water before leaving the area or going to bed. Fires are only in designated fire rings. DO NOT USE INSECT REPELLENT NEAR CAMPFIRES.

12 13 Camper Policy Earn Your Way to Camp

It is expected that all Scouts, Scouters, leaders, parents, and visitors at Mitigwa Scout Reservation will live up to the principles and values of the Scout Oath and Law. SAMPLE SAMPLE The following information should be shared before arriving at camp. 1. The Scout Oath and Law are the rules at camp. They are all that is needed and unit leadership is responsible for enforcing these rules and disciplining those Camp Cards Scouts/Adults that break them. Each Camp Card sells for $5 and includes excellent deals at local vendors. For 2. In the case of inter-unit conflicts or problems, the unit leadership of the each Camp Card sold, your unit earns $2.50. These funds can be used to send your individual Scouts/Adults are responsible for the discipline of each individual Scout/ Scouts to Summer Camp; to Council, District, and unit events; to update books and Adult. uniforms; and more! 3. The Camp Administration (beginning with the Camp Commissioner) is Visit https://scoutingiowa.org/camp-cards/ to find out more information! available and prepared to assist in establishing communication in the event of inter- unit problems. Workership Program 4. If the Camp Administration (including the Reservation Director) believes Mid-Iowa Council has a long history of serving youth. Throughout our twenty-seven counties, further disciplinary action is required of the unit leadership, they will request it. If we serve more than 20,000 members annually. not forthcoming, the chartered partner, District Executive, and Scout Executive will Understanding that different Scouts have different needs, many of which are financial, itis be contacted and informed. important for us as an organization to do our best to help all youth. No Scout should be unable 5. The Camp Administration encourages unit leadership to send any Scout/Adult to fully participate in Scouting due to lack of funds. To help Scouts help themselves we have developed the “Workership Program.” home immediately who steals, vandalizes or intentionally places another Scout in What is it? danger (whether physical or mental). The Camp Administration reserves the right The “Workership Program” is a way for Scouts to earn their way to a Mid-Iowa Council camp or to take action themselves if necessary. This includes sending the entire unit home for many other Scouting needs. The concept is that a Scout needing help will perform community within 24 hours. service to earn their way. However, this program is not designed to be a “blank check.” There 6. The has a zero-tolerance policy for hazing and must be a significant need and each application will require the approval of parent/guardian, unit leader, and service project recipient. bullying. Should you be concerned about hazing or bullying while at camp, please alert a staff member immediately. Workerships are for Mid-Iowa Council camps, activities, and supply needs (books, uniforms, 7. Scouts are required to be in their campsite by lights out. Any Scout that must etc...) only. All information will be kept confidentially on file at the Maytag Scout Center. leave the campsite after 10:00 pm, must be accompanied by an adult leader or camp The Workership service project MUST be completed and the Workership approved BEFORE staff member. Remember always follow two-deep leadership policies and no one- arriving at camp. To learn more and to apply, visit Https://scoutingiowa.org/scout-assistance/ and download the Workership Request Form. on-one contact.

14 15 2021 Session Fees and Refunds While Registering Remember:

Session Fees 2020 Through March 31st Beginning April 1st Cub Overnighter $70 $90 per participant Camp T-Shirts: Bear Camp $95 $115 Camp Akela 2021 t-shirts are available for pre-order online. There is a pre-order deadline of per participant May 9th. A limited number of 2021 Camp Akela t-shirts will be available at the Trading Post. Webelos Camp $120 $140 Please plan ahead and use the pre-order option. per participant Pack Resident $120 $140 Dietary Restrictions: per participant ●The registration system allows for input of special dietary needs. Be sure your Scout’s information is updated accordingly online prior to registering for camp. 50% due at time of registration -- Entire balance due by June 1, 2021 ●If a dietary accommodation does not get added when registering for camp, please call the Maytag Scout Center or email [email protected] to ensure proper meals are Cancellations fee: Akela provided. From April 2nd to June 1st there will be a $30 fee for any Scout or Adult that is canceled ●Cold and dry storage is available for Scouts or leaders who require a special diet and choose to (transfers are allowed) After June 1st, there are no Refunds allowed except per the regular Council Refund Policy bring their own food. Health Forms: Refund Policy: ●Every Scout and leader going to Cub Scout Resident camp must present upon arrival a Our Registration & Refund policy has been crafted to achieve a balance between meeting participant completed Annual Health & Medical Record, Parts A & B, signed by a parent or guardian. expectations of a quality experience while meeting the fiduciary responsibilities of the Council. ●Blank medical forms are available at Roundtables and at the Maytag Scout Center, or at the Our event, activity, and camp budgets are planned to have minimal margins in order to keep the costs within the reach of every Scouting family. However, almost all events have upfront costs and overhead expenses (site BSA national website: Annual Health and Medical Record. Medical forms will be returned to reservation fees, patches, food, program supplies, etc.) that must be secured in advance of the event to meet leaders when they check-out. participant expectations. ●Mitigwa Scout Reservation has a qualified health professional on-site around the clock to Sometimes a pre-paid participant elects not to attend an event. This could, for example, be due to a family provide medical assistance to individuals during camp. situation or simply a choice to not attend due to the weather forecast. Either way this doesn’t change the fact that goods and services were purchased on the participant’s behalf in expectation of their attendance. Medications: On September 1, 2016 the following board-approved guidelines took effect: If your Scouts require medication, we ask that you follow several basic steps: 1. A participant or Unit is not considered to be registered for an event until all fees are paid in full. ●Gather information on the dosage requirements of each medication for each Scout from the 2. All payments of fees for District and Council events are non-refundable except under the following Annual Health & Medical Record section on Prescription medications. conditions: ●This form gives permission to Pack leaders to dispense medication to Scouts at the times 1. Serious Illness, must be accompanied by a doctor’s note 2. Death in family designated by the parent/guardian or as indicated on the prescription. 3. Special unexpected and extraordinary circumstances ●All medications, prescription and non-prescription, need to be in their original containers. 4. Event is canceled ●Request a lock box to keep track of all medications not requiring refrigeration. This locked In cases where a refund may be considered, the request must be in writing (email or post), include a copy of box is to be kept in the campsite. Arrange with the Camp Health Officer to store refrigerated the receipt, and be submitted to the Council Office within 15 calendar days after the end of the event. Requests medications in the Camp Office. Help your Scouts get their medications on time, including made after 15 days will not be considered. those medications stored at the Camp Office. In the event a refund is approved, it shall be disbursed in keeping with Mid-Iowa Council policies and procedures for disbursement of funds. In the case of a unit registration, the unit will receive the refund. All ●If refrigeration or electrical hook up is needed, please contact the Camp Director before you refunds, excluding cancellation, will be less twenty-five percent (25%) of the activity fee to cover liquidated arrive. costs incurred in preparation of the activity. EXCEPTIONS include medication that must be kept on the person such as asthma inhalers 16 17 Getting to Camp Akela Map of Camp Akela Map of Camp

18 19 Notes:

20 Part A: Informed Consent, Release Agreement, and Authorization A Part B1: General Information/Health History B1

Full name: ______High-adventure base participants: Full name: ______High-adventure base participants: Expedition/crew No.: ______Expedition/crew No.: ______Date of birth: ______or staff position: ______Date of birth: ______or staff position: ______

Age: ______Gender: ______Height (inches): ______Weight (lbs.): ______Informed Consent, Release Agreement, and Authorization Address: ______I understand that participation in Scouting activities involves the risk of personal injury, including I also hereby assign and grant to the local council and the Boy Scouts of America, as well as their City: ______State: ______ZIP code: ______Phone: ______death, due to the physical, mental, and emotional challenges in the activities offered. Information authorized representatives, the right and permission to use and publish the photographs/film/ about those activities may be obtained from the venue, activity coordinators, or your local council. videotapes/electronic representations and/or sound recordings made of me or my child at all Unit leader: ______Unit leader’s mobile #: ______I also understand that participation in these activities is entirely voluntary and requires participants Scouting activities, and I hereby release the Boy Scouts of America, the local council, the activity to follow instructions and abide by all applicable rules and the standards of conduct. coordinators, and all employees, volunteers, related parties, or other organizations associated Council Name/No.: ______Unit No.: ______with the activity from any and all liability from such use and publication. I further authorize the In case of an emergency involving me or my child, I understand that efforts will be made to reproduction, sale, copyright, exhibit, broadcast, electronic storage, and/or distribution of said Health/Accident Insurance Company: ______Policy No.: ______contact the individual listed as the emergency contact person by the medical provider and/or photographs/film/videotapes/electronic representations and/or sound recordings without limitation adult leader. In the event that this person cannot be reached, permission is hereby given to the at the discretion of the BSA, and I specifically waive any right to any compensation I may have for medical provider selected by the adult leader in charge to secure proper treatment, including any of the foregoing. Please attach a photocopy of both sides of the insurance card. If you do not have medical insurance, enter “none” above. hospitalization, anesthesia, surgery, or injections of medication for me or my child. Medical providers are authorized to disclose protected health information to the adult in charge, camp Every person who furnishes any BB device to any minor, without the express or implied permission In case of emergency, notify the person below: medical staff, camp management, and/or any physician or health-care provider involved in of the parent or legal guardian of the minor, is guilty of a misdemeanor. (California Penal Code providing medical care to the participant. Protected Health Information/Confidential Health Section 19915[a]) My signature below on this form indicates my permission. Information (PHI/CHI) under the Standards for Privacy of Individually Identifiable Health Information, Name: ______Relationship: ______45 C.F.R. §§160.103, 164.501, etc. seq., as amended from time to time, includes examination findings, test results, and treatment provided for purposes of medical evaluation of the participant, I give permission for my child to use a BB device. (Note: Not all events will include BB devices.) Address: ______Home phone: ______Other phone: ______follow-up and communication with the participant’s parents or guardian, and/or determination of the participant’s ability to continue in the program activities.  Checking this box indicates you DO NOT want your child to use a BB device. Alternate contact name: ______Alternate’s phone: ______

(If applicable) I have carefully considered the risk involved and hereby give my informed consent NOTE: Due to the nature of programs and activities, the Boy Scouts of Health History for my child to participate in all activities offered in the program. I further authorize the sharing America and local councils cannot continually monitor compliance of program Do you currently have or have you ever been treated for any of the following? of the information on this form with any BSA volunteers or professionals who need to know of participants or any limitations imposed upon them by parents or medical medical conditions that may require special consideration in conducting Scouting activities. providers. However, so that leaders can be as familiar as possible with any Yes No Condition Explain limitations, list any restrictions imposed on a child participant in connection with Diabetes Last HbA1c percentage and date: Insulin pump: Yes £ No £ With appreciation of the dangers and risks associated with programs and activities, on my programs or activities below. own behalf and/or on behalf of my child, I hereby fully and completely release and waive Hypertension (high blood pressure) any and all claims for personal injury, death, or loss that may arise against the Boy Scouts List participant restrictions, if any:  None of America, the local council, the activity coordinators, and all employees, volunteers, Adult or congenital heart disease/heart attack/chest pain (angina)/ related parties, or other organizations associated with any program or activity. ______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.

I understand that, if any information I/we have provided is found to be inaccurate, it may limit and/or eliminate the opportunity for participation in any event or activity. If I am participating at Stroke/TIA , Philmont Training Center, Northern Tier, Sea Base, or the Summit Bechtel Reserve, I have also read and understand the supplemental risk advisories, including height Last attack date: and weight requirements and restrictions, and understand that the participant will not be allowed to participate in applicable high-adventure programs if those requirements are not Asthma/reactive airway disease met. The participant has permission to engage in all high-adventure activities described, except as specifically noted by me or the health-care provider. If the participant is under the age of 18, a Lung/respiratory disease parent or guardian’s signature is required. COPD Participant’s signature: ______Date: ______Ear/eyes/nose/sinus problems

Parent/guardian signature for youth: ______Date: ______Muscular/skeletal condition/muscle or bone issues (If participant is under the age of 18) Head injury/concussion/TBI

Altitude sickness

Psychiatric/psychological or emotional difficulties Complete this section for youth participants only: Neurological/behavioral disorders Adults Authorized to Take Youth to and From Events: Blood disorders/sickle cell disease Fainting spells and dizziness You must designate at least one adult. Please include a phone number. Kidney disease

Name: ______Name: ______Seizures or epilepsy Last seizure date:

Phone: ______Phone: ______Abdominal/stomach/digestive problems Thyroid disease

Skin issues Adults NOT Authorized to Take Youth to and From Events: Obstructive sleep apnea/sleep disorders CPAP: Yes £ No £

Name: ______Name: ______List all surgeries and hospitalizations Last surgery date:

List any other medical conditions not covered above Phone: ______Phone: ______

21 22 680-001 680-001 2019 Printing 2019 Printing Part B2: General Information/Health History B2

Full name: ______High-adventure base participants: Expedition/crew No.: ______Date of birth: ______or staff position: ______

Allergies/Medications DO YOU USE AN EPINEPHRINE  YES  NO DO YOU USE AN ASTHMA RESCUE  YES  NO AUTOINJECTOR? Exp. date (if yes) ______INHALER? Exp. date (if yes) ______

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

Yes No Allergies or Reactions Explain Yes No Allergies or Reactions Explain

Medication Plants

Food Insect bites/stings

List all medications currently used, including any over-the-counter medications.  Check here if no medications are routinely taken.  If additional space is needed, please list on a separate sheet and attach.

Medication Dose Frequency Reason

 YES NO Non-prescription medication administration is authorized with these exceptions: ______Administration of the above medications is approved for youth by: ______/ ______Parent/guardian signature MD/DO, NP, or PA signature (if your state requires signature)

Bring enough medications in sufficient quantities and in the original containers. Make sure that they are NOT expired, including inhalers and EpiPens. You SHOULD NOT STOP taking any maintenance medication unless instructed to do so by your doctor.

Immunization The following immunizations are recommended. Tetanus immunization is required and must have been received within the last 10 years. If you had the disease, check the disease column and list the date. If immunized, check yes and provide the year received. Please list any additional information about your medical history: Yes No Had Disease Immunization Date(s) ______Tetanus ______Pertussis ______Diphtheria ______Measles/mumps/rubella

Polio DO NOT WRITE IN THIS BOX. Review for camp or special activity. Chicken Pox Reviewed by: ______Hepatitis A Date: ______Hepatitis B Further approval required:  Yes  No Meningitis Reason: ______Influenza Approved by: ______Other (i.e., HIB)

Exemption to immunizations (form required) Date: ______

23 24 680-001 2019 Printing