USAGSO-West Pacific Presents: Mt. Fuji Leadership Climb Adventure

USAGSO-West Pacific Presents: Mt. Fuji Leadership Climb Adventure Pre-requisites

Prospective Mt. Fuji Leadership Climb Adventure Participants (girls and adults) below you will find the check list and links to the mandatory pre-requisites for attending the July 20th-July 23rd Mt. Fuji three night event. Please note that by registering for this event, you are agreeing to complete the pre-requisites. Refunds will not be given out to individuals (adults and girls) who do not complete the pre-requisites and who are not able to attend this event. Register at this event at www.westpacificgirlscouts.com on the program page.

A quiz will be sent out prior to the event to girls and adults participating in the climb to ensure that they have reviewed the necessary materials.

Education Pre-Requisites:

□ I have read the attached Mt. Fuji Information Sheet and understand the risks involved, the length of the climb, and the physical demands of the climb. □ I have watched both the short educational documentaries on Mt. Fuji: o http :// www . natgeoeducationvideo . com / film /627/ mt -fuji o http :// dsc . discovery . com / videos / discovery - atlas - japan - mount - fuji .html

Physical Conditioning Pre-Requisites: □ I have read the mandatory conditioning pre-requisites and agree to document the completion of the progression activities Packing/Supply Pre-Requisites: □ I have read and agree to have the proper and mandatory clothing, shoes, backpack, and equipment as stated in the Packing/Supply list. Signature/Approval Pre-Requisites: □ I have read the 3 Approval documents and agree to get a signed approval from the following: o A parent/guardian that can attest to your emotional and physical readiness for this activity. o A Girl Scout Volunteer that knows you well and can attest to your emotional and physical readiness for this activity. (Girls and Adults) o A physical education teacher or personal trainer/gym staff employee who can attest to your physical readiness for this activity.(Girls and Adults) Physical Medical Exam Pre-Requisite: □ I agree to turn in a signed physical medical exam completed within the last 12 months prior to the completion date of the Mt. Fuji Leadership Climb Adventure (July 21st). Due no later than May 1st. (Girls and Adults)

!, ______agree to all of the above. (participant’s name)

Name of Participant Signature of Participant

Name of Parent/Guardian Signature of Parent/Guardian (Not Needed if Adult Participant)

Contact Information for Parent/Guardian

First and Last Name: OC: Email Address: Phone Number: USAGSO-West Pacific Presents: Mt. Fuji Leadership Climb Adventure Physical Conditioning Pre-requisites

The purpose of this information is to help you set and reach fitness goals. Our training goal is to help you get physically and mentally prepared to fully engage in the sport of hiking. Your climbing goal will be to perform strong and steady throughout your adventure. Sound fitness gained through a well-guided program is the best way you can ensure a safe and successful tour.

Mt. Fuji 2 Day Tour The Goal: Be able to carry a 25-pound pack for five hours on 20-degree rocky slopes. Be able to ascend steadily for 5,000 feet (slopes up to 40 degrees) in seven hours. Then be able to descend 9,000 feet (slopes up to 40 degrees) in six hours.

The Fitness Program Start your entire fitness training program well in advance of your climb, and increase the intensity and duration of your exercising as you gain fitness. Typically, 6 weeks minimum is needed to implement an effective program.

We recommend starting physical training and practice hikes 2-3 months prior, but this training program is for 6 weeks prior to the climb:

Your first weeks in this new fitness program will most likely be focused on getting into a routine. The more your training can simulate real climbing, the more you will benefit. The following exercises can be used in your fitness program. Use aerobic exercises to develop cardiovascular fitness. There are a variety of aerobic exercises which are fantastic for training. They include: climbing and descending hills, stairs or stadium bleachers, any kind of skiing, snowboarding, running and cycling.

In addition to the benefit of cardiovascular fitness, there needs to be concentrated effort on developing your aerobic ability for the descent from the summit. Many climbing accidents occur on the decent of Mt. Fuji. A good strengthening program for the legs, especially quadriceps and knees, can really pay off. When training with a pack, use a bathroom scale to ensure it is the proper weight. Some training recommendations for aerobic exercising include:

(1) Keep your training range at 65 to 85% of your maximum heart rate. There is a well known formula for ascertaining your maximum heart rate that is based on your age, which you subtract from the number 220 (beats per minute). Arbitrary at best. We suggest that you begin with that formula, and then be aware of how you feel. Your perceived exertion can actually be a better indicator of how you ought to be performing on a given day. Individually, we differ enough, and certainly we have good days and bad days, such that “how we feel” should come into play. For example, a 39 year old has a maximum heart rate of 181; i.e., 220 - 39 = 181 beats per minute. The training range, then, is between 118 and 154 beats per minute.

(2) We recommend that the time you spend working aerobically should be a solid 30 minutes a day, and shouldn’t exceed 60 minutes. In order to train for the lengthy days in the mountains, you’ve got to get out and do lengthy training climbs; nothing else will prepare you as adequately.

(3) The frequency of your aerobic workout can be rather unlimited. You can train every day if you like. Be careful that you don’t overdo it and set yourself up with injuries. You should include some rest time each week. Use interval training to advance your cardiovascular fitness. The technique of interval training calls for including surges in the activity while maintaining an elevated heart rate. Here are some examples: (1) If you are a runner, begin by running at a moderate intensity for twenty minutes. Every ten minutes thereafter, increase your pace for three to eight minutes, then return to the moderately intense level. (2) If you are at the track, run around the track once at a moderate pace. Sprint 220 yards, then run one lap again. Repeat. (3) If you are using a step mill, step moderately (at the high end of your aerobic training range) for ten minutes. Every five minutes thereafter, increase your pace for 1 to 1½ minutes, then return to moderate intensity. Remembering that the heart’s ability to pump blood to the body is a major limiting factor in our athletic performance, then here is a training technique which can help us overcome that limitation. What we are doing here is going beyond standard cardiovascular fitness. Interval training, when used over a longer period of time, can aid in increasing the heart’s capacity for pumping blood throughout the body.

This is a very strenuous manner of training, and it shouldn’t be initiated at the last minute. We have had success with interval training when we have a minimum of two to three months training time. The mandatory physical conditioning log is for 6 weeks prior. SAMPLE WORK-OUTS

Below are sample workouts which we have found successful. This program develops both cardiovascular and motor fitness. We have intentionally omitted describing the specific mechanics of the workouts as there exists a huge arsenal of exercises and machines to match an individual’s personal situation (personal history and present fitness level).

Although on Fuji, you won’t be carrying a very heavy pack, pack weights do add a new dimension to our physical activities. These training principles are essentially the same for our upper and lower bodies.

Stretching, balance, aerobic and abdominal exercises can be done every day. You should work with lower body and upper body weights at least twice a week (once every 3 days). Don’t fail to include a good warm up and warm down in your workout.

Warming up and warming down Include 10 to 15 minute aerobic warm up and a 5 to 10 minute warm down in your program. This is an important component of any program. Keep your heart rate in an aerobic range; don’t get anaerobic.

Examples include walking, jogging in place, step mills, treadmills, cycling, and jumping rope.

Stretching Include 15 minutes of quality stretching into your program. Focus on slow, static stretching. Avoid bouncing, ballistic stretching. With static stretching, hold the stretch for 30 to 60 seconds, breathing through the stretch. Hold it only to the point of tension, not to the point of pain. Don’t stretch through pain; you are stretching and tearing muscle fibers with this activity. Be patient. The reward of proper stretching is the joy of increased movement as a result. Stretch at the beginning of a workout, just after the warm up, and also, even more importantly, after the workout when the muscles are at their warmest and most supple state. Stretching after a workout will do a tremendous amount ofgood toward alleviating muscle soreness and decreasing the chance of injury.

Lower Body Weights: (1) 1 to 2 sets of calf raises. Use a platform which allows you to make the full range of motion as you stand up on your toes and then drop your heels. Use body weight only. (2) 2 sets of leg curls. Your hams should be 1/3 to 1/2 as strong as your quads. (3) 2 sets of individual leg extensions. (4) 2 sets of squats. Use a machine to isolate the gluteal muscles and prevent back injury. Upper Body Weights: (1) Begin by exhausting the larger muscles first. This includes the chest, back, and shoulders. (2) Work both the biceps and the triceps. Points to focus on: (1) All weight sets should be performed focusing on excellent form and technique. You should hire a physical trainer for at least a day to assist you with developing good technique. It may also be beneficial to meet again with this person periodically to ensure good form and to measure progress. (2) Perform repetitions with a two-count positive motion and a four-count negative motion. (3) Breathe out on exertion. (4) Use proper rest periods between sets. (5) With all these exercises, slowly increase the weights over time. Be patient. (6) Tendon strength increases at a rate roughly ten times less quickly than muscles. Don’t supercharge your muscles on an aggressive weight program only to injure your tendons.

Abdominal Exercises Focus on the quality of the exercise, not the number. Changing up the exercises (cross-training the abdomen) is key to increasing abdominal fitness. The abdominal muscles adapt remarkably well to a punishing workout – continue to change up your workout, even if you don’t switch exercises, switch the routine.

Balance Exercises Balance exercises reward you with increased body awareness and can aid in your ability to negotiate tricky terrain under a heavy pack. Distinguish between static and dynamic balance exercises. Static exercises will keep one or both feet on the ground. Dynamic exercises involve the body in motion. Both are important for the development of this motor fitness skill. Balance is a motor skill like strength, and can be improved over time. Include some of these into your workout. Here are some possibilities: Static Balance Exercises: (1) Walk heel-to-toe in a straight line. Then return by walking backward. Then try with your eyes shut. (2) Stand in balance on one leg. Fold the other leg beneath you and hold it by the knee or foot. (3) Stand in balance on one leg, then squat, and then return to the stand position. (4) Try the same exercise, but standing on a piece of foam. Dynamic Balance Exercises: (1) Skiing, snowboarding, roller skating, ice skating are obvious and fun. (2) Tennis, racquetball, basketball and volleyball are all also great for balance. (3) Clamber up and down hills, the hard way – over rough trails, through the woods, etc. This is a particularly effective exercises. USAGSO-West Pacific Presents: Mt. Fuji Leadership Climb Adventure Physical Conditioning Training-Log

6 Weeks Prior to Climb □ 30 Minutes of Cardiovascular Activity 4 times a week. □ 30 Minutes of Static and Dynamic Balance Activities twice a week. □ 20 Minutes of Lower and Upper Body Strength Training 2 Times a week.

4 Weeks Prior to Climb □ Carry a 15lb back-pack on a 2 Hour Hike with a lot of ups and downs. □ 30 Minutes of High Interval Cardiovascular Activity 3 Times a week. □ 30 Minutes of Lower and Upper Body Strength Training 2 Times a week. □ 15 Minutes of Static and Dynamic Balance twice a week.

3 Weeks Prior to Climb □ Carry a 15lb back-pack on 3 Hour Hike with a lot of ups and downs. □ 30 Minutes of High Interval Cardiovascular Activity 3 Times a week increasing interval levels. □ 30 Minutes of Lower and Upper Body Strength Training 2 Times a week. □ 15 Minutes of Static and Dynamic Balance twice a week.

2 Weeks Prior to Climb □ Carry a 20lb back-pack on 4 Hour Hike with a lot of ups and downs. □ 30 Minutes of High Interval Cardiovascular Activity 3 Times a week increasing interval levels. □ 30 Minutes of Lower and Upper Body Strength Training 2 Times a week. □ 15 Minutes of Static and Dynamic Balance twice a week.

1 Week Prior to Climb □ Carry a 25lb back-pack on 4 Hour Hike with a lot of ups and downs. □ 30 Minutes of High Interval Cardiovascular Activity 3 Times a week increasing interval levels. □ 30 Minutes of Lower and Upper Body Strength Training 2 Times a week. Remember the more real to life hiking you do, the better prepared you will be!

I, ______feel physically prepared to hike Mt. Fuji. I have completed all of the above training pre-requisites. My daughter/ward ______has completed all of the above physical training pre-requisites. ______Date______THIS FORM IS FOR GIRL AND ADULT PARTICIPANTS USAGSO-West Pacific Presents: Mt. Fuji Leadership Climb Adventure Mandatory Pack-List/Supplies

The below list is the Mandatory Pack-List ONLY for the overnight excursion on Mt. Fuji. With your confirmation for the entire 3 night event will be additional items needed to sleep at MCB Fuji.

Mandatory □ BACKPACK (A minimum of 30L or 1,500 cubic inch pack is the average recommended size for this hike). A large school backpack is fine for this. Camel backpacks are also recommended. A hip strap is recommended for added comfort. □ BASE LAYERS: Insulating thermal underwear for both top and bottom is mandatory. These should be made from wicking materials (draws moisture/sweat away from the body) and should NEVER be made of cotton. □ OUTER LIGHT LAYERS: T-shirt: Also needs to be made from quick-drying, durable materials such as nylon or athletic (i.e. running/soccer shirt) material. NEVER use cotton. □ Pants/trousers: These need to be made of quick-drying, durable materials such as nylon or athletic material. NEVER use jeans or any kind of cotton. □ HEAVY INSULATING LAYER: This will keep you warm! Remember that the temperature at the summit will feel like -10c/15f. In these temperatures you must stay warm. This insulating layer needs to provide that ability. Usually a fleece or wool upper body garment, i.e. a fleece jacket will do the trick. Remember this item needs to have the ability to be layered over your base layer top and under your shell jacket and insulating parka. □ SHELL JACKET: You will need a jacket made of rain/wind resistant material with an attached hood. Ideally this jacket is waterproof/breathable (Gore-tex) fabric. Second best would be a simple plastic rain jacket that can be found at stores in Japan for 500yen. □ SHELL PANTS: Pants made of rain/wind resistant material will be needed for the climb. For maximum comfort and an enjoyable experience, these pants should be made of waterproof/breathable fabric. Second best are simple plastic rain pants that can be bought in Japan for 500 yen. Summary -Upper body: Thermal base layer - Athletic T-shirt - Fleece garment - Outer shell -Lower body: Thermal base layer - Athletic Pants - Shell Pants □ FOOTWEAR: Ideal: Waterproof ankle supporting hiking boots. These will stabilize your ankle and keep your feet dry in the cold rain. The other less ideal option is comfortable ankle supporting athletic shoes. Be sure to APPLY WATERPROOFING SPRAY to your shoes prior to your climb. Be aware that if your athletic shoes get wet and the weather is inclement, you may be forced to stay in a mountain hut until favorable weather due to the risk of frost-bite. This is the risk you take by using athletic shoes instead of waterproof boots. □ GOOD SOCKS: You will want one or two changes of socks, either wool or synthetic, but NEVER cotton. Use liner socks (a thin silky sock that minimizes friction between your sock and your foot) if you have not had time to break in your boots or if you are prone to blisters. □ GLOVES: These keep your fingers warm in freezing temperatures and high winds. Fleece is ideal because it is insulating even when wet. □ WARM HAT: It is a known fact that 70% of your body heat escapes through your head. So put a plug on it. Use a warm fleece/wool beanie to keep your head warm in the cold. This will also help regulate your body temperature. □ SUNSCREEN: UV rays are exponentially more potent in higher elevations. It is not uncommon to get burned even in cloudy weather. Bring one tube of SPF 15 or higher. □ HEADLAMP: In order to make it in time for the sunrise on Mt. Fuji we will be making a very early start and traveling about 4-6 hours in the dark. Be sure to bring extra batteries. □ SUNGLASSES (Available for rental ¥1,000) It can get very bright on the mountain, these will prevent your eyes from getting sunburned (it does happen). Sunglasses will also protect your eyes from the dusty paths encountered, especially on the descent. It is recommended that you bring polarized sunglasses which are made specifically to protect your eyes in high altitude environments. □ 2 LARGE GARBAGE BAGS When it rains, you want to be prepared. Placing all of your clothing inside of a trash bag will waterproof everything inside the trash bag. In the event of rain, you will be happy knowing that your warm clothing will still by dry by the time you get to the mountain hut. □ 1 LARGE ZIP-LOCK BAG Please use this as your personal trash bag. □ TOILET ARTICLES: Glasses/contacts, deodorant, toothbrush, toothpaste and a few hand/sanitary wipes. Bring some personal toilet paper for your climb. There are pit-toilets on Mt. Fuji; they cost 200JPY per use. □ SNACKS / SOUVENIR MONEY Girl Scouts will provide 4 meals once we begin our climb (lunch and dinner the 1st night and breakfast and lunch the second day). You will need to bring snacks and money for any other snacks or souvenirs you may want. We suggest bringing crackers, candy bars, jerky, chips, cookies, trail mix, fruits, energy bars, and hard candies. Add peanut butter, cream cheese, hard cheese, or pepperoni for additional calories and taste. If you enjoy bread items, bagels work well. Include some salty snacks to replenish lost salts. Remember you have to carry what you bring in and out. RECOMMENDED ( BUT NOT MANDATORY) PACK LIST:

□ INSULATED PARKA It may be hard to believe, but during the summer, the summit of Fuji is often below freezing. The purpose of this oversized, insulated parka is to trap our heat if we have to sit still for any period of time during the climb. We will, for example, throw on this insulated parka during our rest stops and while waiting for the sunrise on top of Mt. Fuji. The parka may be either goose down or synthetic fill. □ HIKING POLES (Available for rental ¥1,000 for 2) Having a pair of hiking poles plays a major role in reducing stress to your knees and back. Hiking poles will help you keep your balance in general. Mt. Fuji wooden poles can be bought at the 5th station for receiving stamps and are good for souvenir, but they are not the best for climbing. Blisters on the hand are a common aftereffect from using Mt. Fuji’s wooden poles. □ GAITERS (Available for rental ¥700) Small ankle-length gaiters big enough to cover the area from the top of your boot to the area above your ankle. These will keep pebbles and rocks from entering your boots. This is not a "must" because duct tape makes a suitable substitute for gaiters on the mountain. □ BACKPACK RAIN COVER (Available for rental ¥700): Most backpacks are not waterproof and mountain weather is extremely unpredictable. With a rain cover handy for your backpack, you can continue climbing with the reassurance that your clothes and other valuables will stay dry! Bringing along extra clothes, only for them to get wet, won’t do you any good! □ SHORTS and T-SHIRT: Nice for hiking on warm days. □ 2 or 3 1L WATER BOTTLES: You have two options; pack water in with you or buy it at a mountain hut as you go up. If you choose the latter option, remember that the cost of water on Mt. Fuji is 500 yen per 500ml (half liter). Usually 3 liters is sufficient for the climb. □ SPENDING MONEY. Mt. Fuji is riddled with all kinds of little souvenir shops. We recommend bringing about JPY5,000-10,000 for gifts and keep sakes. □ BALL CAP: A lightweight ball cap, bandana or sun hat for hot days. USAGSO-West Pacific Presents: Mt. Fuji Leadership Climb Adventure Girl Scout Parent Recommendation

Climbing Mt. Fuji is an incredible challenge that we hope that many of our Girl Scout girl members and volunteers are able to experience while living in the West Pacific. It is a very physically and emotionally challenging climb with many inherent risks including altitude sickness, frostbite, wind- burn, and other risks of injury. USAGSO-WP wants to ensure that the participants of this event are prepared and ready to take on this challenge.

Although, we are completing this climb over two days and hiring an experienced bi-lingual guide to accompany us, the climb will not be easy. There will not be an option to turn back as the route we are taking up the mountain and the route back are on two different paths and it is quite dangerous to climb down the ascending route especially at night. The participants will be climbing in the late-afternoon to evening and waking up at 2:30AM to climb to the summit before sunrise. This means that the participants will be climbing in the dark using headlamps to guide them.

In order to ensure that our girl participants are as prepared as possible for this trip we are mandating the following: A physical test conducted by a PE teacher, physical trainer, sports coach (or the equivalent) verifying that she is ready for this climb, a signed form by a GS volunteer and the girl’s parent/guardian stating that she is ready for this challenge, and a sports/medical physical conducted within the last 12 months. Additionally, each participant and her parent must sign the physical conditioning training log.

I ______, parent/guardian of______believe that she is emotionally and physically prepared to climb Mt. Fuji.

In the condition that she is not emotionally or physically prepared for this climb and must be transported via the emergency vehicles on the mountain, I agree to assume all liability including additional expenses. Parent Signature USAGSO-West Pacific Presents: Mt. Fuji Leadership Climb Adventure Girl Scout Volunteer Recommendation

Cli Climbing Mt. Fuji is an incredible challenge that we hope that many of our Girl Scout girl members and volunteers are able to experience while living in the West Pacific. It is a very physically and emotionally challenging climb with many inherent risks including altitude sickness, frostbite, wind- burn, and other risks of injury. USAGSO-WP wants to ensure that the participants of this event are prepared and ready to take on this challenge.

I ______, holding the Girl Scout Volunteer Position of______believe that ______is emotionally and physically prepared to climb Mt. Fuji.

Volunteer Signature

THIS FORM IS FOR GIRL AND ADULT PARTICIPANTS. USAGSO-West Pacific Presents: Mt. Fuji Leadership Climb Adventure Physical Education Teacher/Personal Trainer Approval

Climbing Mt. Fuji is an incredible challenge that we hope that many of our Girl Scout girl members and volunteers are able to experience while living in the West Pacific. It is a very physically and emotionally challenging climb with many inherent risks including altitude sickness, frostbite, wind- burn, and other risks of injury. USAGSO-WP wants to ensure that the participants of this event are prepared and ready to take on this challenge.

I ______, believe that ______is physically prepared to climb Mt. Fuji.

______Signature, Position THIS FORM IS FOR GIRL AND ADULT PARTICIPANTS. USAGSO-West Pacific Presents: Mt. Fuji Leadership Climb Adventure Overview and FAQ Agenda Sunday, July 20th 1:00PM Leave Camp Zama 3:00PM-5:00PM Arrive at MCB Fuji, Get Settled/Ice-Breakers. 4:00PM-5:00PM Dinner 5:00PM-7:00PM Safety-Briefings and Climbing Prep. 7:00PM-9:00PM Media Equipment Overview/Slumber Party

Monday, July 21st Climb Mt. Fuji 5:00AM-6:00AM Wake Up/Pack-Up 6:00AM-6:30AM Breakfast 7:00AM-8:00AM Bus-Ride to Mt. Fuji 8:00AM-9:00AM Meet Guide at and Acclimate 9:00AM-6:00PM Climb (Lunch at 6th Station) 5:00PM-6:00PM Arrive at Fujisan Hotel/Eat Dinner 7:00PM Sleep

Tuesday, July 22nd Climb Mt. Fuji 2:00AM Wake Up/Pack-Up 2:30AM-4:30AM Climb to the Top 4:30AM Sunrise Girl Scout Own Ceremony 5:00AM-6:30AM Optional Circuit of Crater 6:30AM-7:30AM Breakfast In Hut 7:30AM-1:00PM Make the Descent 12:00PM-1:00PM Lunch at 5th Station/Meet Bus 1:00PM-3:00PM Bus back to MCB Fuji 3:00PM-5:00PM Rest/Showers 5:00PM-6:00PM Dinner 6:00PM-10:00PM Create Multi-Media Presentation, Movies, Debrief Experience

Wednesday, July 23rd Final Day 6:30AM-7:00AM Wake-Up 7:00AM-8:00AM Breakfast 8:00AM-9:00AM Pack-Up 10:00AM Get Picked Up/Bus back to Zama Information about Climbing Mt. Fuji Climbing Mount Fuji (3776 meters), Japan's highest and most prominent mountain, can make for lifelong memories. The mountain itself may look more attractive from afar than from close up, but the views on clear days and the experience of climbing through the early morning hours among hundreds of equally minded hikers from across the world, are very rewarding.

When to climb?

Official Climbing Season

July and August are the official climbing season. During these two months the mountain is usually free of snow, the weather is relatively mild, access by public transportation is easy and the mountain huts are open. Everybody without much hiking experience is strongly advised to tackle the mountain during the official climbing season.

The Crowds

Climbing Mount Fuji is very popular not only among Japanese but also foreign tourists, who seem to make up more than a third of all hikers. The peak season for climbing Mount Fuji is during the school vacations which last from around July 20 to the end of August.

In order to encounter neither too large nor too small crowds, we recommend to climb Mount Fuji on a weekday in the first half of July before the start of the school vacations. The downside of a climb in early July is the weather, which tends to be somewhat more unstable than later in the season.

Near the summit

Subashiri 5th Station (Subashiri Trail) access - hotels - reports - tours

Medical Examination Record

Medical Examination: A Medical Examination Record is completed for trips lasting more than three nights or determined high adventure by USAGSO-WP. The examination is completed by a licensed physician, nurse practitioner, physician’s assistant or registered nurse within the preceding 24 months unless a health issue is present

Girl Name: Date:

(This section is to be completed by a physician after the review of health history with parent/guardian. Parent/Guardian must complete all the information of the Health History Form to the best of their knowledge and sign before meeting with licensed professional.)

Medical Examination – Must be completed in detail. Height: Weight: B. P.: / Hearing: R L Eyes: With Glasses R 20/ L 20/ Without Glasses R 20/ L 20/ Code: S = Satisfactory NS = Not Satisfactory NE = Not Examined Nose Abdomen Urinalysis* Other: Throat Hernia HGB* Teeth Genitalia Appearance/Nutrition Heart Skin General Physical State Lungs Musculoskeletal General Emotional State *Girls should have this test if she had not had it since entering puberty.

Record of Immunization – Must be completed in detail.

Date Series Year of Date Series Year of was Completed Last Booster was Completed Last Booster Hep B Typhoid DTap/Tdap Paratyphoid DT/Td Cholera Hib Yellow Fever IPV/OPV Typhus PCV7 Rocky Mountain MMR Spotted Fever Varicella Tuberculin Test: Year last given Result

Other: Not required immunizations, but recommended HPV Rota MCV4/MPSV4 Hep A

Personal and religious beliefs dictate against immunizations: Yes No

Physician Information

Licensed Physician Name: (Last, First, Middle Initial) Phone Number:

Address: City: St: Zip:

This person is in satisfactory condition and may engage in all usual activities, including physically demanding activities except as noted. Signature of Licensed Physician:

State License Number: Date:

HEALTH INFORMATION PRIVACY STATEMENT The Health History and Medical Examination Form for Minors is for health care concerns at the specified event only. All records will be handled by staff/volunteers whose job includes processing or using this information for the benefit of the participant. All medical records will be held in limited access by the health care supervisor for the specific event. Minimal necessary information may be shared with event staff/volunteers in order to provide adequate participant safety and health care. This form will be retained for seven years past the age of maturity of the participant. Access to the information will be limited, but copies may be requested from the event sponsor, by the participant or their legal representative. I have read the above procedures for handling the health and medical form and I agree to the release of any records necessary for treatment, referral, billing or insurance purposes.

THIS FORM IS FOR GIRL AND ADULT PARTICIPANTS