Leader Guide - Jayhawk Area Council

Transcripción

JAYHAWK AREA COUNCIL
2013 Camp Jayhawk
Unit Leader
Guide
Unit leaders
Dear Scoutmaster and Camp Leaders:
As your Camp Jayhawk Camp director I want to invite you to Camp. I would love to get to know
you and your Scouts. I have been involved in Jayhawk Area Council over the last 25 years as a
Webelos Den Leader, Assistant Scoutmaster, Scoutmaster, OA Lodge Adviser, Area 5 OA Section
Advisor, COPE Director, Climbing Instructor, Woodbadge Course Director and Powder Horn Course
Director. I spent 9 straight summers attending Camp Jayhawk with my troop. In addition I served
on staff in the past as an Outpost Director (Wilderness Survival and Camping). I am looking
forward to serving this and future summers as Camp Director.
Camp Jayhawk on Falley Scout Reservation is open and available for you, your troop and individual
Scouts to experience the Camp Jayhawk Experience. It is so exciting this year as new facilities
continue to be constructed even as you read this letter. We’re working on a new Welcome Center
consolidating the office, the camp director quarters, trading post, health lodge and guest
restrooms which we all hope will serve you better. A new shooting sports area is in place with new
rifle range and archery range nearby the shotgun range. The Climbing facilities are being
revamped providing a more complete climbing program in addition broadening the scope of the
program to include Cub Scouts.
As you know, a good summer camp experience is vitally important to retaining Scouts in the troop.
The Staff and my goal is to provide the best experience we can to cement the bonds that keep
Scouts in the troop and coming back to Camp Jayhawk. We have a skilled, experienced staff that
can make and exceed our common goal. I will continue to keep the door open to you so we can
discuss your experience. Remember feedback is a gift. We can never know how we are doing
unless we hear from you and your Scouts.
Thank you for attending Camp Jayhawk and let’s make this summer memorable.
Yours in Scouting,
George Austin, Camp Director
785-224-9526
[email protected]
Session Dates and Camp Fees
4
Refund Policy
5
Online Registration
5
Camp Check In
8
Camp Contact Information
10
Leaving Camp Early
12
Visitors at Camp
12
Page 2
2013 Camp Jayhawk
Pre - Camp
Information
Camp Jayhawk
2012 Session Dates
Session 1
June 9-15
Session 2
June 23-29
Merit Badge Camp
July 1-3
Session 3
July 7-13
Camp Fees
Traditional Camp - (Includes Baden Powell Adventure, Merit Badges, Training Opportunities, BSA
Lifeguard, C.O.P.E, FSR News Team, Camp Shirt, etc.)
Scout Fee: $210 by May 1st. $225 after May 1st.
Leader Fee: $100 for full week. $15 per day for part-time leaders
A campsite reservation fee of $200 must be paid by the troop before boys and leaders
can register or pay camp fees.
Merit Badge Immersion Camp (Camp Shirt included)
Scout Fee: $100
Leader Fee: $50
Scouts may attend with or without their troop. If a troop is attending together, they need to
reserve a campsite.
All-Star Camp (NEW PROGRAM)
An individual Scout may be unable to attend summer camp with his troop due to scheduling or
location. Since it is important to give Scouts a summer camp experience, Camp Jayhawk is
providing an opportunity for the Scout to be part of an All-Star troop in camp. The All-Star troop
is a provisional troop with volunteer adult leadership of Scoutmaster experienced adults. The
Scout will have the opportunity to register as an individual Scout and participate in the summer
camp programs including the Baden Powell Adventure during the 2nd and 3rd Sessions of Camp.
Registered Adults may also register to attend camp and provide leadership for the All-Star troop.
This program is not intended to serve as a substitute for unit camp attendance under the
Traditional Camp.
Scout Fee: $210 by May 1st. $225 after May 1st.
Leader Fee: $100 For Full Week.
***Limited Camperships are available to Jayhawk Area Council units. Please complete the
Campership Request Form (page A-1) or download from www.jayhawkcouncil.org/and return it
to the Scout Service Center in Topeka, no later than April 15, 2013.
Page 4
2 0 1 3 C A M P J AY H A W K
Payment Schedule
At date of reservation: Pay $200.00 non-refundable campsite deposit.
By April 1st: First payment is due (1/2 BALANCE OWED).
By May 1st: Final payment due (balance due on your account).
Reservations made by May 1st will be guaranteed a camp t-shirt
Reservations placed after May 1st will be accepted only with a minimum 1/2 payment at that
time.
Refund Policy
All refund requests must be submitted to the camp director or Scout Service Center prior to the
start of a camp session.
•
Refund requests must be submitted on the Camp Refund Request Form (page A-2).
•
Please attach a copy of proof of payment (receipt) with refund request.
•
Please print all information. All blanks must be completed. Incomplete forms will be returned
for completion.
•
Refunds are reviewed by the appropriate camping committee and take 4-6 weeks to process.
•
Refunds will be issued to the unit account, or to the original payee (if payment was by unit
check, then refund will be issued to the unit, not to an individual).
•
Only refunds received in the Scout Service Center prior to May 1 will be considered for a full
refund. Cancellations, with legitimate reasons, after May 1 will be subject to a 20% nonrefundable portion assessed for food, equipment and program supply purchases. Refund
requests submitted after the camp session will not be considered.
•
A Scout or unit leader may request a refund under the following conditions: illness or serious
accidents of the Scout or Family illness or emergencies preventing the Scout’s attendance at
camp. Camp fees are non-refundable for homesickness, scheduling conflicts (sporting events,
music camp, family vacation, etc) or weather conditions. No refunds will be issued for early
departures from camp.
Online Registration
The Online Merit Badge registration system will be available early March. The online system
will allow troop leaders to select merit badge classes, see costs associated with each class, make
adjustments up to one week before camp starts, and make final camp payments online. It is
important to register as soon as possible as some camp programs and merit badge classes have a
maximum number of participants allowed. Also, some programs and merit badges have costs to
cover special supplies. When a Scout is signed up for an activity with a cost, the cost will be
added to the units invoice for camp. These supplies will be given upon check-in or in some cases
in the class.
Page 5
Pre-Camp Orientation
It is recommended that you attend a Pre-Camp Orientation before coming to camp. We have
scheduled a Pre-Camp Orientation at 10 a.m. on April 20, 2013, at the Scout Service Center,
1020 SE Monroe, Topeka, KS. The session should last between one and two hours. You will hear
about any administrative changes, meet some of the staff and review camp policies. This will
also be an opportunity to schedule your arrival times for camp. In case you’re unable to attend
the session on Saturday, a second Pre-Camp Orientation will be held on April 24th at the Scout
Service Center beginning at 7 p.m. You only need to attend one of these sessions. Unit leaders
will also be contacted about a week prior to your camp session to alert you on any last minute
adjustments and an opportunity to answer any questions you may have.
Camp Leadership
BSA Policy requires at least two adult leaders, one of whom must be 21 years or older, for all
trips and outings. Each troop must be under the leadership of an adult (over 21 years of age),
preferably the registered Scoutmaster.
If the Scoutmaster is unable to attend full time, the troop committee should name a
Campmaster. He assigns and coordinates responsibilities of all adult leadership in his troop.
All additional adult leaders staying with the troop in Camp Jayhawk are considered Assistant
Scoutmasters. It is the responsibility of the entire troop leadership, both youth and adult to
maintain discipline in troop at all times while at Camp Jayhawk. At Camp Jayhawk, only
activities that meet the standards of the twelve points of the Scout Law are permitted. Your
cooperation and understanding in helping us maintain high standards of moral and personal
behavior is appreciated. The Camp Director or designee reserves the right to remove individuals
who are not in compliance with BSA and Falley Scout Reservation policies.
Each adult leader brings a unique set of life skills to camp. Some camp programs and merit
badge classes may be able to use those skills to enhance the educational experience in these
areas. Leaders are encouraged to sign up to attend camp programs where they feel they can
best offer support to the staff member in charge of the area. In addition, older boys who help in
the Baden Powell area may be recognized for their support as an honorary staff member.
Health and Medical Record
Scouts and leaders staying at Camp Jayhawk must have a fully completed annual BSA Health
Examination Form (page A-3). Scouts and leaders without a current physical examination cannot
be permitted to remain in Camp Jayhawk, in compliance with National standards of the BSA. No
health form, no overnight stay at Camp Jayhawk, no exceptions! Physical examinations are not
provided at Camp Jayhawk. It is recommended that all campers receive a tetanus shot before
camping.
A copy of your Scouts’ medical forms must be kept in the Health Lodge so we urge Troops to
bring 2 copies with them (leave the original at home). One copy is for the troop to keep and
one copy will be turned in to the Health Officer upon check-in.
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2012 CAMP JAYHAWK
2013 Camp Jayhawk
Your Stay at
Camp
Camp Check In
The entire staff is committed to a smooth arrival at camp and an easy transition to your camp
site. Plan to arrive to Camp Jayhawk on Sunday at your arrival time agreed upon during your
pre-camp call the week before. If you did not receive an arrival time please call the Camp’s
Office at 785-876-2465. We will do our best to accommodate your desired time of arrival.
Your campsite hosts will meet your troop at or near the parking lot when you arrive.
Page 8
1.
Upon arrival, have your troop’s Campmaster and Senior Patrol Leader proceed to
the Welcome Center for check-in. The Campmaster should take with him the
Health Forms for the entire Troop and any forms or registration information that
need to be turned in to the office.
2.
The Campmaster will verify with the office staff that all the registration
information is correct and that all fees have been paid. The Campmaster will also
turn in Early Release Forms, Payment for Visitors' Meals and any other
administrative information.
3.
Remember that Scouts cannot leave camp early without an early release form and
the parent picking them up showing proper identification. The Campmaster will
receive identification wrist bands for each Scout and adult. This is an important
tool to help recognize unauthorized people on camp and ensure the safety of each
camper on FSR. These wristbands will be worn at all times. This wristband will also
serve as your meal ticket during the week.
4.
The Campmaster will turn in the Health Forms to the Camp Health Officer. The
Health Officer may ask to talk to select Scouts individually from the troop that
have certain special conditions or that are participating in physically demanding
activities such as C.O.P.E. or High Adventure so that he can be aware of special
physical needs or conditions in the event of an emergency.
5.
A list of all prescription medications for each person must also be given to the
Health Officer. The Campmaster will receive a lock box for those medicines.
Refrigeration is available in the health lodge for those medications that are
required to be temperature controlled. Prescriptions will come to Camp Jayhawk in
their original containers. Scoutmasters are responsible for issuing easily dispensed
medicines.
6.
The Campmaster and Senior Patrol Leader will proceed to the Trading Post to pick
up camp T-shirt and materials for merit badges. These merit badge materials are
paid for as part of the camp fees in the office. Please inventory these merit badge
supplies upon arrival at your campsite. If there are any issues, please contact the
Camp Director so exchanges can be made.
2 0 1 3 C A M P J AY H A W K
7.
The troop will regroup and travel down to the swim dock to do swim checks. It is
recommended that Scouts arrive in swim trunks so that they do not need to change
twice in the swimming area. Make sure Scouts bring a towel. Swim checks are
required for anyone wanting to do an activity requiring a Swimmer or Beginner
status.
8.
During swim checks, one or more leaders will be allowed to drive one vehicle at a
time on camp to transport your troop’s gear to its campsite. (These leaders can take
their swim checks after they unload the gear in the campsite or at another time
scheduled with the Aquatics Director.) One vehicle will be allowed to go to the
campsite at a time and must have a vehicle pass signed by the Camp Director. Your
vehicle will be admitted on Falley Scout Reservation by a member of the camp staff
or a Camp Master and should be driven to your campsite, unloaded, and returned to
the parking lot as soon as possible. The leaders can make several trips in different
vehicles.
9.
Troops are allowed to leave a trailer at the entrance of their campsite that will
remain the duration of the week until check-out on Saturday. No vehicles are to
remain in the campsite. No one under 18 years of age is to ride in a vehicle on
camp property and no riders are allowed in beds of pickups.
10. After swim checks the troop will move to Bell Lodge to pick up cleaning supplies and
toilet paper for their latrine, sleeping pads for adult leaders, and a dining fly if
requested.
11. The troop will then proceed to their campsite, and with the help of their Campsite
Host, they will set up camp.
12. The troop should report to Flag Ceremony at 5:50 P.M. in field uniform. Also
remember to send waiters to the Dining Hall 15 minutes before dinner. There should
be 2 waiters for every table that the troop occupies in the dining hall (or
approximately 2 Scouts for every 9 members of the troop).
Page 9
Camp Contact Information
Parents are encouraged to write to their Scout while at camp. U.S. Mail will be placed in the
troops’ mailboxes located in the camp office, by 2:30 p.m. each day. If parents wish to contact
their child by phone, it is best to call an adult leader from the troop who has a cell phone.
Calls to and from the camp office should generally be for camp business only. Outgoing mail is
picked up from the camp office by 11:30 a.m. each morning.
Your Scout’s Name and Troop #
Campsite Name
Falley Scout Reservation
8602 Kingman Road
Oskaloosa, KS 66066
Important Phone Numbers
Falley Scout Reservation: 785-876-2465
Council Office: 785-354-8541
Council Fax: 785-354-8722
Camp Office Hours
The Falley Scout Reservation office is located in the Welcome Center . Office hours will be
from 8:00 a.m. to 12:00 p.m. and 1:00 to 4:30 p.m.
Campsites
Each campsite is divided into conservation areas. Please see to it that the unit only camps in
the area that is marked for camping. Each campsite is provided with wall tents designed to
house two Scouts or leaders, a small floorboard for the middle of the tent, and a metal cot for
each person. Troop campsites have washstands and latrine facilities. Showers for all campers
are available at the west side shower or the central shower. Troops will be assigned to clean
these showers at the daily leader meetings. Troops may bring private tents. Tents must meet
the BSA standards of 30 sq. feet per camper and must post “No flame in tents” signs. Ditching
of tents (digging of ditches around the tent to allow for rainwater runoff) is not allowed per
BSA policy.
Supplies at Camp
Camp Jayhawk provides limited supplies at each camp site and supplies to incoming troops
such as toilet paper and cleaning supplies. Supplies from the quartermaster will be checked
out to each unit during check in. Please ensure that these items are returned to the
quartermaster prior to departure.
Camp Jayhawk Provides
Items from the Quartermaster
Flagpole per campsite
Toilet paper
Dining Fly (on request)
Latrine and water supply
Trash bags
Burn Barrel (on request)
Picnic table per campsite
Broom
2-man A-frame wall tents
Cleaning supplies for latrine
One cot per camper or leader
Small hose
One floorboard per tent
Cot pads (for adult leaders only)
Page 10
*Additional items such as tools
may be available on request
2 0 1 3 C A M P J AY H A W K
Facilities for Scouts with Physical Disabilities
Red Cedar campsite was developed for Scouts who have a physical disability. It will
accommodate a limited number of Scouts. Prior arrangements must be made with the Camp
Director to ensure the needs of disabled Scouts and leaders can be met. Falley Scout
Reservation will make every effort to accommodate those individuals with physical disabilities.
Firearms, Weapons, Drugs, and Alcohol
Personal firearms, fireworks, ammunition, and bow-hunting equipment are strictly prohibited
on Falley Scout Reservation. Camp Jayhawk provides all equipment for various field sports
activities. Sheathed knives and other weapons are not allowed at Falley Scout Reservation.
The possession, consumption or use of alcoholic beverages and illicit drugs are strictly
prohibited. Violators will be removed from Falley Scout Reservation.
Falley Scout Reservation is a non-smoking facility, except in a designated area.
Accidents and Illness
All accidents and illnesses must be reported to the Health Lodge and recorded in the Health
Log Book in order for the insurance coverage to be in effect.
Sick call is immediately following breakfast each morning. Non life-threatening injuries can be
seen at the discretion of the Camp Master
Insurance
All Scouts and Scouters registered in the Jayhawk Area Council are covered by a year-round
accident insurance policy as a part of the council service to our membership. All accidents and
illnesses must be reported to the Health Lodge and recorded in the Health Log Book in order for
the coverage to be in effect. Please note that the insurance provided by the council is a
secondary policy; THE FAMILY’S INSURANCE IS BILLED FIRST, with BSA insurance providing up
to the first $300 of coverage.
Units camping at FSR from other councils need to bring a copy of their current Certificate of
Insurance that provides youth and adult coverage while at camp.
Emergency Procedures and Heat Warnings
Emergency procedures will be carefully reviewed upon your arrival at camp. Copies of Camp
Jayhawk Emergency Action Plan are posted in each program, activity, and administrative area.
A warning system will be in place for heat advisories. At high heat and humidity levels, program
and activities that require a high degree of physical activity may be restricted and sales of
pop/slushies may be temporarily discontinued. Heat warning information will be reviewed daily
at leader and SPL meetings.
Page 11
The Buddy System
All Scouts will follow the buddy system by moving in at least groups of two in camp. At no time
should a buddy leave a Scout alone in any Merit Badge venue or in the camp site. If, while
moving around camp, Scouts sees a visitor without visitor identification, he and his buddy are
to report this immediately to the nearest adult leader or camp staff member.
Vehicles in Camp
Troops are only allowed to have vehicles inside camp during hours specified for check-in and
check-out with a permit. No other vehicles will be allowed past the gates. Vehicle permits will
be available in the office as necessary at discretion of the Camp Director or Ranger.
Leaving Camp Early
Campers and adults who leave Camp Jayhawk during the week must sign out at the camp
office. Campers may leave only with a written release (Planned Early Departure Form, A-4)
from a parent or guardian, on which the name of the individual transporting the camper
must be specified. This person will need to present proper identification before leaving
with a Scout. Scouts will not be released to an individual if they are not specified by name
on the early release form or they do not have proper identification. Planned Early Departure
Forms must be turned in during the check-in process.
Visitors at Camp
Visitors are welcome especially during Family Night on Friday Evening. Visitors are required to
sign in at the camp office before entering any part of Falley Scout Reservation and receive a
visitor identification lanyard. Family Night is an opportunity to celebrate the Scouts' success at
camp. Families are invited to join in the activities starting at 5:00 p.m. Many units make this a
gala troop/family event by having picnics near the Parade Grounds or at the campsite or by
eating as a group in the dining hall. Flag ceremony on Friday will be held at 5:50 p.m. and
dinner will be served from 6:00 through 7:00 p.m.
If visitors choose to eat the meal provided by Camp Jayhawk, meal tickets for Friday’s dinner
may be purchased in the camp office or during online registration for $7.00 each. This is a
buffet style barbecue meal. If you will be having guests come for dinner on Friday evening in
the dining hall, you should register and/or pay for them at check-in.
Please use appendix A-5 and include it with your visitor meal payment at check-in. Guest
meals can also be paid for online with Troop registration. All visitors that will be eating guest
meals will be given a wristband as a meal ticket.
Due to the number of visitors and guests on Friday evening, NO vehicle will be allowed beyond
the gates after 4:00 p.m. except for camp support vehicles.
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2 0 1 3 C A M P J AY H A W K
Flag Ceremony
Prior to the morning and evening meals, the entire camp assembles on the Parade Ground for
the raising and lowering of the flag. It is the tradition of Camp Jayhawk for the Scouts and
leaders to be in full uniform (activity uniform for the morning flag ceremony and field uniform
for the evening flag ceremony) as we pay respect to our country’s flag. Troops may volunteer
for Flag Ceremony duty by signing up in the camp office.
Religious Services
Scouts will have an opportunity to attend an all-faith retreat on Sunday evening at the All
Faiths Chapel. There is also an all-faith worship service (Vespers) on Wednesday evening. Any
religious groups are welcome to hold their own services. Please coordinate the use of chapel
facilities with the Camp Director. Daily reflections are also encouraged in each unit’s individual
campsite.
Chili/Cobbler Cook Off and Competition
On Monday Night, we invite all troops to the area immediately in front of the dining hall for a
chili and cobbler competition. This competition accomplishes two things. It allows all the
troops to come together and rekindle old friendships and to see who has the best chili and
cobbler as chosen by a panel of camp staff chili and cobbler experts.
Camp Jayhawk provides tomatoes, beans, precooked meet and chili powder for your chili and
cake mix and fruit filling for your cobbler. Please remember to bring with you all your “secret
ingredients” from home.
Trading Post
The Falley Scout Reservation Trading Post is stocked with merit badge items, souvenirs, snacks,
T-shirts, camping gear, hats and drinks.
Some merit badges require special items to complete that merit badge. If you have preregistered and prepaid for that class, these kits will be ready for your troop during check-in.
However, if additional kits must be purchased, please take this into consideration when sending
spending money with your Scout to camp.
Trading Post Hours* (Monday – Friday)
8:30 - 12:15 p.m.
1:30 - 5:30 p.m.
7:00 - 9:00 p.m.
*Note: The Trading Post will be closed during campfire programs. The Trading Post reserves the
right to close its pop and snack sales if camp litter or heat becomes a problem.
Page 13
Leader Training and Service Opportunities
In addition to the merit badge and other activities, there are several opportunities for adults to
receive additional training and service opportunities. Training will be available generally in ½
hour to 1 hour blocks during the day in appropriate program areas. You can find many of these
under the Basic Training Block in other activities of the Merit Badge Guide. You should sign up at
the Camp Office for these activities.
Examples of training to be offered are:
Safety begins with Leadership (Offered at the Camp Leader Orientation Session prior to camp.)
Youth Protection training, (Available at camp, however, leaders and youth should take the online
course prior to arriving in camp)
Safety Afloat
Safe Swim Defense
Weather Hazards
Climb on Safely
Baden-Powell Patrol Skill Instructor training (Recommended for Leaders with Campers in the BadenPowell Adventure). This is a daily training on different skill areas.
Chain Saw Safety
Geocaching
Trek Safely
Mentoring
Nature Trail Orientation
Examples of Service in Camp
Order of the Arrow
Trail building and maintenance (This can be a troop service project or a leader group project)
Invasive plant removal
Russian Thistle
Western Cedar
Maintenance and repair of camp facilities or equipment
Nature Trail maintenance
We hope this information will answer all your pre-camp questions, but if it does not, feel free to
contact us at:
George Austin , Camp Director
785-224-9526
[email protected]
Angie Madill, Receptionist
785-276-3344
[email protected]
2 0 1 3 C A M P J AY H A W K
2 0 1 3 C A M P J AY H A W K
Jayhawk Area Council
Boy Scouts of America
2013 Boy Scout Summer Camp Scholarship Application
Campership requests must be received in the Scout Service Center no later than April 15, 2013
Name: _______________________________________________ Troop # _________________
Address: _____________________________________________ Phone # ________________
Planning to attend Camp Jayhawk on: ______________________
I hereby apply for financial aid for attending Boy Scout Summer Camp through the Jayhawk Area Council.
Summer camp scholarships will only be given for up to 50% of the fee. Please complete the information below
as to how the balance of the money will be obtained as well as all following sections. Incomplete applications
cannot be considered.
Total
Amount Troop will help Scout: ......................................................... $___________
Family Contribution: ---Youth $_____ Parents $_________ .......... $___________
Other Contributions (list source): ..................................................... $___________
Scholarship Requested: (Up to 50% of fee is maximum) ............. $___________
Section I – Participation Information
I have participated in the following fund raising activities. (Check all that apply):
___ Popcorn sales
___ Pancake Feed
___ Greenery Sale
___ Candy Bar sales
___ Chili Feed
___ Garage/Bake Sale
___ Other Troop Fund-raisers (explain): ________________________________________
I have participated in the following Scout activities (check all that apply):
___ Klondike Derby
% of Troop Activities ___ 25% ___ 50% ___75% ___ 100%
___ Camporee
% of Troop Meetings ___ 25% ___ 50 % ___75% ___ 100%
___ Boy Scout Lock-In
___ Other Troop Activities (explain): ___________________________________________
I have earned the following Scout ranks in the past year (check all that apply):
___ Scout Badge
___ 2nd Class
___ Star
___ Tenderfoot
___ 1st Class
___ Life
___ Eagle
Section II – Financial Information
Does the family qualify for the free or reduced lunch program?
____Free Lunch Program
OR
____Yes
____No
____Reduced Lunch Program
Section III – Parents Comments (Please list any comments that would be beneficial in considering this request.)
Comments:____________________________________________________________________________
(use back ____________________________________________________________________________
side if
____________________________________________________________________________
needed) ____________________________________________________________________________
Parent’s Signature: ____________________________ Phone # (H)______________(W)______________
Section IV – Leader’s Comments (Please list any comments that would be beneficial in considering this request.)
Comments: __________________________________________________________________________
(use back
__________________________________________________________________________
side if
__________________________________________________________________________
needed)
__________________________________________________________________________
Leader’s Signature: ____________________________ Phone # (H)_____________ (W)_____________
District Executive’s Signature:_____________________________________________________________
Office Use Only
Approved $________
Denied _______
-A-1-
Date:_________
Jayhawk Area Council
Boy Scouts of America
Camp Refund Request Form
All refund requests must be submitted to the camp director or Scout Service Center prior to the
start of a camp session.
• Please attach a copy of proof of payment (receipt) with refund request.
• Please print all information. All blanks must be completed. Incomplete forms will be returned for
completion.
• Refunds are reviewed by the appropriate camping committee and take 4-6 weeks to process.
• Only refunds received in the Scout Service Center prior to May 1 will be considered for a full refund.
Cancellations, with legitimate reasons, After May 1 will be subject to a 20% non-refundable portion
assessed for food, equipment and program supply purchases. Refund requests submitted after the
camp session starts will not be considered.
• A Scout or unit leader may request a refund under the following conditions: illness or serious
accidents of the Scout or Family illness or emergencies preventing the Scout’s attendance at camp.
Camp fees are non-refundable for homesickness, scheduling conflicts (sporting events, music camp,
family vacation, etc) or weather conditions. No refunds will be issued for early departures from camp.
Camper Name:
Troop/Pack:
Council:
Camper Address:
City/State/Zip:
Camper Phone:
Camper is: Youth
______
Adult
(Circle one)
Camp Registered to attend: (check one)
Cub Scout Day Camp/Twilight Camp location:
________________________
Fun with Son – camp dates:
Webelos Resident - camp dates:
Camp Jayhawk - camp dates:
Dates attended camp (if any):
Fees paid: $
Describe reason for refund request: (please be as specific as possible. See above for refund conditions.
Use back of form if needed.)
Select method of refund:
Deposit refund into unit account at Scout Service Center
Check (If payment was by unit check, the refund will be issued to the unit.)
Person requesting refund (print name):
Date:
Signature:
Phone:
Phone:
Unit Leader Name:
Unit Leader e-mail address:
_________________
Office use only: Date Received in Service Center:
Amount approved $
by
date
(staff name)
by
Refund processed on date:
-A-2-
Annual Health and Medical Record
Registro Médico y de Salud Anual
(Valid for 12 calendar months)
(Válido por 12 meses calendario)
Policy on Use of the Annual Health
and Medical Record
Política para el uso del Registro Médico
y de Salud Anual
In order to provide better care for its members and to assist
them in better understanding their own physical capabilities,
the Boy Scouts of America recommends that everyone who
participates in a Scouting event have an annual medical
evaluation by a certified and licensed health-care provider—a
physician (MD or DO), nurse practitioner, or physician assistant.
Providing your medical information on this four-part form will
help ensure you meet the minimum standards for participation
in various activities. Note that unit leaders must always protect
the privacy of unit participants by protecting their medical
information.
A fin de proporcionar una mejor atención para sus miembros
y para ayudarles a entender mejor sus propias capacidades
físicas, Boy Scouts of America recomienda que todos aquellos
que participen en un evento Scouting se sometan a un examen
médico anual realizado por un prestador de servicios de salud
certificado y con licencia: un médico (Doctor en medicina o
Doctor en osteopatía), enfermera profesional o asistente médico.
Proporcionar su información médica en este formulario de cuatro
partes, ayudará a asegurar que usted cumple con los estándares
mínimos de participación en varias actividades. Tome en cuenta
que los líderes de unidad siempre deben proteger la privacidad
de los participantes al salvaguardar su información médica.
Parts A and B are to be completed at least annually by
participants in all Scouting events. This health history, parental/
guardian informed consent and release agreement, and
talent release statement is to be completed by the participant
and parents/guardians. Attach a copy of both sides of your
insurance card.
Part C is the pre-participation physical exam that is required
for participants in any event that exceeds 72 consecutive
hours, for all high-adventure base participants, or when the
nature of the activity is strenuous and demanding. Service
projects or work weekends may fit this description. Part C is
to be completed and signed by a certified and licensed heathcare provider—physician (MD or DO), nurse practitioner, or
physician assistant. It is important to note that the height/
weight limits must be strictly adhered to when the event will
take the unit more than 30 minutes away from an emergency
vehicle, accessible roadway, or when the program requires
it, such as backpacking trips, high-adventure activities, and
conservation projects in remote areas. See the FAQs for when
this does not apply.
Part D is required to be reviewed by all participants of a highadventure program at one of the national high-adventure bases,
as well as unit-based, high-adventure backcountry activities,
and shared with the examining health-care provider before
completing Part C.
• Philmont Scout Ranch. Participants and guests for Philmont
activities that are conducted with limited access to the
backcountry, including most Philmont Training Center
conferences and family programs, will not require completion
of Part C. However, participants should review Part D to
understand potential risks inherent at 6,700 feet in elevation
in a dry Southwest environment. Please review specific
registration information for the activity or event.
• Northern Tier National High Adventure Base.
• Florida National High Adventure Sea Base. The PADI medical
form is also required if scuba diving at this base.
• Summit Bechtel Reserve.
Las Partes A y B las deben completar, por lo menos una vez
al año, los participantes de todos los eventos Scouting. Este
historial médico, notificación de consentimiento y convenio de
exoneración de responsabilidad por parte de los padres/tutores,
y formulario de cesión de derechos lo deben completar los
participantes y los padres/tutores. Anexar una copia de ambos
lados de su tarjeta del seguro.
La Parte C es el examen físico previo, que se requiere de
los participantes de cualquier evento que exceda 72 horas
consecutivas, para todos los participantes de las bases de
aventura extrema, o cuando la naturaleza de la actividad es
extenuante y exigente. Los proyectos de servicio o fines de
semana de trabajo pueden caer en esta descripción. La Parte
C la debe completar y firmar un prestador de servicios de salud
certificado y con licencia: un médico (Doctor en medicina o
Doctor en osteopatía), enfermera profesional o asistente médico.
Es importante tomar en cuenta que los límites de estatura y peso
deben ser estrictamente controlados cuando el evento llevará a
la unidad a más de 30 minutos de un vehículo de emergencia,
camino accesible, o cuando el programa lo requiera, tal como
expediciones, actividades de aventura extrema y proyectos
de conservación en áreas remotas. Consulte las Preguntas
Frecuentes para cuando estos lineamientos no aplican.
La Parte D se requiere que la revisen todos los participantes del
programa de aventura extrema en una de las bases nacionales de
aventura extrema, así como actividades de aventura extrema en
zonas aisladas basadas en la unidad, y que la compartan con el
prestador de servicios de salud antes de completar la Parte C.
• Rancho Scout Philmont. Los participantes e invitados en las
actividades Philmont que se realicen con acceso limitado a las
zonas campestres, incluyendo la mayoría de las conferencias
y programas familiares en el Centro de Capacitación Philmont,
no requerirán llenar la Parte C. Sin embargo, los participantes
deberán repasar la Parte D para entender los riesgos
potenciales inherentes a los 6,700 pies de elevación en un
ambiente seco del Suroeste. Favor de revisar la información
de registro específica para la actividad o evento.
• Base nacional de aventura extrema Northern Tier.
• Base nacional marina de aventura extrema de la Florida.
También se requiere el formulario médico PADI si se va a
bucear en esta base.
• Summit Bechtel Reserve.
Risk Factors
Based on the vast experience of the medical community, the
BSA has identified the following risk factors that may limit your
participation in various outdoor adventures.
• Excessive body weight
• Heart disease
• Hypertension (high blood
pressure)
• Diabetes
• Seizures
• Lack of appropriate
immunizations
• Asthma
• Allergies/anaphylaxis
• Muscular/skeletal
injuries
• Psychiatric/
psychological and
emotional difficulties
Factores de riesgo
Con base en la gran experiencia de la comunidad médica, BSA
ha identificado los siguientes factores de riesgo que podrían
limitar su participación en varias aventuras al aire libre.
• Peso corporal excesivo
• Enfermedad cardiaca
• Hipertensión (Presión
arterial alta)
• Diabetes
• Convulsiones
• Falta de vacunación
adecuada
• Asma
• Alergias/anafilaxia
• Lesiones musculares/
óseas
• Trastornos psiquiátricos/
psicológicos y
emocionales
For more information on medical risk factors, visit Scouting
Safely on www.scouting.org.
Para obtener más información sobre los factores de riesgo
médicos, visite Scouting Safely en www.scouting.org.
Prescriptions
The taking of prescription medication is the responsibility of the
individual taking the medication and/or that individual’s parent or
guardian. A leader, after obtaining all the necessary information,
can agree to accept the responsibility of making sure a youth takes
the necessary medication at the appropriate time, but the BSA
does not mandate or necessarily encourage the leader to do so.
Also, if state laws are more limiting, they must be followed.
Prescripciones
Tomar los medicamentos prescritos es responsabilidad del
individuo que requiere el medicamento o del padre de familia
o tutor del individuo. Un líder, después de haber obtenido toda
la información necesaria, puede aceptar la responsabilidad de
asegurarse de que un niño tome el medicamento necesario a la
hora apropiada, pero BSA no obliga ni necesariamente anima
al líder a que lo haga. Asimismo, si las leyes estatales son más
limitantes, deben ser cumplidas.
Frequently Asked Questions (FAQs)
• Philmont Scout Ranch: www.philmontscoutranch.org or
575-376-2281
• Northern Tier National High Adventure Program:
www.ntier.org or 218-365-4811
• Florida National High Adventure Sea Base:
www.bsaseabase.org or 305-664-5612
• National Scout jamboree: www.bsajamboree.org
• Summit Bechtel Reserve: www.summitblog.org or
304-250-6750
For frequently asked questions about this Annual Health and
Medical Record, see Scouting Safely online at
http://www.scouting.org/scoutsource/HealthandSafety.
aspx. Information about the Health Insurance Portability and
Accountability Act (HIPAA) may be found at www.hhs.gov/ocr/
privacy/.
Preguntas frecuentes
• Rancho Scout Philmont: www.philmontscoutranch.org
ó 575-376-2281
• Base nacional de aventura extrema Northern Tier:
www.ntier.org ó 218-365-4811
• Base nacional marina de aventura extrema de la Florida:
www.bsaseabase.org ó 305-664-5612
• Jamboree Scout Nacional: www.bsajamboree.org
• Summit Bechtel Reserve: www.summitblog.org
ó 304-250-6750
Para consultar las preguntas frecuentes sobre este Registro
Médico y de Salud Anual, consulte Scouting Safely en línea en
http://www.scouting.org/scoutsource/HealthandSafety.aspx. La
información sobre la Ley de responsabilidad y transferibilidad de
seguros médicos (HIPAA, por sus siglas en inglés) se encuentra
en www.hhs.gov/ocr/privacy/.
680-001
2012 Printing
Rev. 9/2012
Parte A Nombre completo
Fecha de nacimiento Alergias
Teléfono en caso de emergencia
Part A Full name:_________________________________DOB:________________ Allergies:___________________ Emergency contact No.:______________
Annual Health and Medical Record
Registro Médico y de Salud Anual
Part A/Parte A
High-adventure base participants:
Participantes en la base de aventura extrema:
Expedition/crew No.
Expedición/grupo no.:_______________________________
or staff position
o puesto fijo: ______________________________________
GENERAL INFORMATION/INFORMACIÓN GENERAL
Name ____________________________________________________ Date of birth ___________________________________ Age ____________ Nombre Fecha de nacimiento (MM/DD/Year) - (MM/DD/Año) Edad Male Masculino
Female
Femenino
Address ______________________________________________________________________________________________ Grade completed (youth only)______________________
Domicilio
Grado escolar completado (sólo niños)
City __________________________________________________________ State______________ Zip ______________________ Phone No. _______________________________
Ciudad Estado Código postal No. telefónico
Unit leader ____________________________________________________ Council name/No. ___________________________________________ Unit No. ___________________
Líder de la unidad Nombre y no. del concilio No. de unidad
Social Security No. (optional; may be required by medical facilities for treatment)___________________________________ Religious preference ________________________
No. de Seguro Social (opcional; puede ser solicitado por las instalaciones médicas para brindar tratamiento) Preferencia religiosa
Health/accident insurance company ____________________________________________________________ Policy No. ________________________________________________
Compañía de seguro médico/accidental No. de póliza
ATTACH A PHOTOCOPY OF BOTH SIDES OF INSURANCE CARD. IF YOU DO NOT HAVE MEDICAL INSURANCE, ENTER “NONE” ABOVE.
ANEXAR UNA FOTOCOPIA DE AMBOS LADOS DE LA TARJETA DEL SEGURO. SI USTED NO TIENE SEGURO MÉDICO, ESCRIBA “NINGUNO.”
In case of emergency, notify/En caso de emergencia, notificar a:
Name _________________________________________________________________________________ Relationship ____________________________________________________
Nombre Parentesco
Address _______________________________________________________________________________________________________________________________________________
Domicilio
Home phone _________________________________________ Business phone _____________________________________ Mobile phone _______________________________
Teléfono de casa Teléfono de oficina Teléfono móvil
Alternate contact name _____________________________________________________________________ Alternate’s phone ___________________________________________
Nombre de contacto alterno Teléfono del contacto alterno
HEALTH HISTORY/HISTORIAL MÉDICO
Please fill in the bubbles as indicated below:
Por favor rellene los círculos tal como se indica a continuación:
Do you currently have, or have you ever been treated for any of the following?
Incorrect:
¿Tiene actualmente, o ha tenido alguna vez los siguientes?
Yes/Sí
No/No
Incorrecto
Condition/Padecimiento
Asthma
Asma Diabetes
Diabetes Correct:
Correcto
Explain/Explique
Last attack: (MM/YY)
Último ataque: (MM/AA)
%
Last HbA1c: (Percentage)
Última HbA1c: (Porcentaje)
Hypertension (high blood pressure)
Hipertensión (presión alta)
Heart disease/heart attack/chest pain/heart murmur
Enfermedad del corazón/infarto/dolores de pecho/soplo cardíaco
Stroke/TIA
Apoplejía/Accidente isquémico transitorio
Lung/respiratory disease
Enfermedades pulmonares/respiratorias
Ear/sinus problems
Problemas del oído/senos paranasales
Muscular/skeletal condition
Condiciones musculares/óseas
Menstrual problems (women only)
Problemas menstruales (sólo mujeres)
Psychiatric/psychological and emotional difficulties
Dificultades psiquiátricas/psicológicas y emocionales
Behavioral/neurological disorders
Trastornos de conducta/neurológicos
Bleeding disorders
Enfermedades hemorrágicas
Fainting spells
Desmayos
Thyroid disease
Enfermedades de la tiroides
Kidney disease
Enfermedades del riñón
Sickle cell disease
Anemia falciforme
Seizures
Last seizure: (MM/YY)
Convulsiones Última convulsión: (MM/AA)
Sleep disorders (e.g., sleep apnea)
Trastornos del sueño (por ejemplo, síndrome de apnea-hipopnea durante el sueño)
Use CPAP: Usa CPAP
Yes
Sí
No
No
Abdominal/digestive problems
Problemas abdominales/digestivos
Surgery
Cirugía
Last surgery: (MM/YY)
Última cirugía: (MM/AA)
Serious injury
Lesión grave
Excessive fatigue or shortness of breath with exercise
Fatiga en exceso o dificultad para respirar al hacer ejercicio
Other
Otro
Page 1 of 2
PART A (continued on next page)
HEALTH HISTORY/HISTORIAL MÉDICO
Please fill in the bubbles as indicated:
Are you allergic to or do you have any adverse reaction to any of the following?
Por favor rellene los círculos tal como se indica:
¿Es alérgico a, o le causa alguna reacción adversa cualquiera de los siguientes?
Yes/Sí
Correct:
IncorrectoCorrecto
Explain
Allergies or Reaction to
No/No
Incorrect:
Alergias o Reacciones a
Explique
Medication
Medicamentos
Food, plants, or insect bites
Alimentos, plantas o picaduras de insectos
The following immunizations are recommended by the BSA. Tetanus immunization is required and must have been received within the last 10 years. For each
item, indicate if you have been immunized, the date of the immunization (MM/YY), if you have had the disease, and the date (MM/YY).
BSA recomienda las siguientes vacunas. La vacuna contra el Tétanos es obligatoria y debe haberla recibido en los últimos 10 años. Por cada punto, indique si ha sido vacunado, la fecha
en que la recibió (MM/AA), si ha padecido la enfermedad, y la fecha (MM/AA).
Immunized?
Immunizations
¿Vacunado?
Yes/Sí
Date (MM/YY)
Fecha (MM/AA)
Vacunas
No/No
Had Disease?
Date (MM/YY)
¿La ha padecido?
Yes/Sí
Fecha (MM/AA)
No/No
Tetanus
Tétano
Pertussis
Part A Full name: __________________________________________________________ DOB: ____________________
Parte A Nombre completo Fecha de nacimiento
Tos ferina
Diphtheria
Difteria
Measles
Sarampión
Mumps
Paperas
Rubella
Rubéola
Polio
Polio
Chicken pox
Varicela
Hepatitis A
Hepatitis A
Hepatitis B
Hepatitis B
Meningitis
Meningitis
Influenza
Influenza
Other (i.e., HIB)
Otra (por ejemplo, HIB)
Exemption to immunizations claimed (form required).
Exención de vacunas solicitada (formulario obligatorio).
MEDICATIONS List all medications currently used. (If additional space is needed, please photocopy this part of the
health form.) Inhalers and EpiPen information must be included, even if they are for occasional or emergency use only.
MEDICAMENTOS Enumere todos los medicamentos que usa en la actualidad. (Si requiere espacio adicional, favor de sacar una fotocopia de esta
parte del formulario.) Se debe incluir información sobre inhaladores y EpiPen, incluso si son sólo para uso ocasional o en caso de emergencia.
Medication Medicamento__________________________________________
Strength Frequency
Dosis _____________________ Frecuencia _________________
Strength Frequency
No medications
Sin medicamentos
Additional medications (sheet attached)
Medicamentos adicionales (hoja anexa)
Strength Frequency
Approximate date started Approximate date started Approximate date started Reason for medication
Reason for medication
______________________________________________________
______________________________________________________
______________________________________________________
Medication Medication Medication Fecha aproximada de inicio______________________________
Razón del medicamento_________________________________
Medicamento__________________________________________
Strength Frequency
Fecha aproximada de inicio______________________________
Medicamento__________________________________________
Strength Frequency
Medicamento__________________________________________
Strength Frequency
Approximate date started Approximate date started Approximate date started Reason for medication
______________________________________________________
______________________________________________________
______________________________________________________
Administration of the above medications
is approved by (if required by your state):__________________________________________________________/________________________________________________________
La administración de los medicamentos arriba
Parent/guardian signature
and/or
mencionados está aprobada por (si lo requiere su estado)
Firma del padre o tutor
y/o
MD/DO, NP, or PA signature
Firma del Dr., Enfermera
profesional, Asistente médico
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.
Asegurarse de traer los medicamentos en cantidades suficientes y en los envases originales. Asegurarse de que NO ESTÉN
CADUCADOS, incluyendo inhaladores y EpiPens. NO DEBE DEJAR DE tomar cualquier medicamento de mantenimiento a menos
que se lo indique su médico.
Page 2 of 2
680-001
2012 Printing
Rev. 9/2012
Part B Full name: __________________________________________________________ DOB: ____________________
Parte B Nombre completo Fecha de nacimiento
Part B/Parte B
Expedition/crew No./Expedición/grupo no.: _______________________________
or staff position/o puesto fijo: ____________________________________________
Informed Consent and Release Agreement
NOTIFICACIÓN DE CONSENTIMIENTO Y EXONERACIÓN DE RESPONSABILIDAD
I understand that participation in Scouting activities involves
a certain degree of risk and can be physically, mentally, and
emotionally demanding. I also understand that participation in
these activities is entirely voluntary and requires participants to
abide by applicable rules and standards of conduct.
Entiendo que la participación en actividades Scouting implica un cierto
grado de riesgo y que pueden ser física, mental y emocionalmente
agotadoras. Asimismo, entiendo que la participación en dichas actividades
es completamente voluntaria y requiere que los participantes se acaten a
las reglas y estándares de conducta pertinentes.
In case of an emergency involving me or my child, I understand
that every effort will be made to contact the individual listed as the
emergency contact person. In the event that this person cannot
be reached, permission is hereby given to the medical provider
selected by the adult leader in charge to secure proper treatment,
including hospitalization, anesthesia, surgery, or injections of
medication for me or my child. Medical providers are authorized to
disclose protected health information to the adult in charge, camp
medical staff, camp management, and/or any physician or health
care provider involved in providing medical care to the participant.
Protected Health Information/Confidential Health Information (PHI/
CHI) under the Standards for Privacy of Individually Identifiable
Health Information, 45 C.F.R. §§160.103, 164.501, etc. seq.,
as amended from time to time, includes examination findings,
test results, and treatment provided for purposes of medical
evaluation of the participant, follow-up and communication with
the participant’s parents or guardian, and/or determination of the
participant’s ability to continue in the program activities.
En caso de que yo, o mi hijo, nos veamos involucrados en un caso de
emergencia, entiendo que se hará todo lo posible para contactar al
individuo mencionado como persona a contactar en caso de emergencia.
En caso de que dicha persona no pueda ser localizada, por este medio
otorgo permiso al proveedor de servicios médicos seleccionado por el
líder adulto a cargo para asegurar que se proporcione el tratamiento
adecuado, incluyendo hospitalización, anestesia, cirugía o inyecciones
de medicamentos para mí o mi hijo. Los proveedores médicos están
autorizados a compartir información médica protegida con el adulto
a cargo, el personal médico del campamento, la administración del
campamento, o cualquier médico o proveedor de servicios médicos
involucrado en la administración de atención médica al participante. La
Información médica protegida/Información médica confidencial (PHI/CHI,
por sus siglas en inglés) bajo los Estándares de privacidad de información
médica individualmente identificable, 45 C.F.R. §§160.103, 164.501, etc.,
y siguientes como se enmiendan de vez en cuando, incluye resultados
de reconocimientos médicos, resultados de pruebas y tratamiento
proporcionado para propósitos de evaluación médica del participante,
seguimiento y comunicación con los padres o tutor del participante,
y determinación de la habilidad del participante de continuar con las
actividades del programa.
I have carefully considered the risk involved and give consent for
myself and/or my child to participate in these activities. I approve
the sharing of the information on this form with BSA volunteers
and professionals who need to know of medical situations that
might require special consideration for the safe conducting of
Scouting activities.
I release the Boy Scouts of America, the local council, the activity
coordinators, and all employees, volunteers, related parties, or
other organizations associated with the activity from any and all
claims or liability arising out of this participation.
He considerado cuidadosamente el riesgo implicado y he dado el
consentimiento para mí mismo o mi hijo de participar en dichas
actividades. Apruebo que se comparta la información contenida en este
formulario con los voluntarios y profesionales de BSA que necesiten tener
conocimiento de condiciones médicas que puedan requerir consideración
especial para la realización de actividades Scouting de manera segura.
Eximo a Boy Scouts of America, al concilio local, a los coordinadores de la
actividad y a todos los empleados, voluntarios, grupos involucrados u otras
organizaciones asociadas con la actividad, de cualquier y toda reclamación
o responsabilidad que surja a raíz de esta participación.
Without restrictions./Sin restricciones.
With special considerations or restrictions (list)/Con condiciones especiales o restricciones (lista):
________________________________________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________________________________
I hereby assign and grant to the local council and the Boy Scouts
of America the right and permission to use and publish the
photographs/film/videotapes/electronic representations and/or
sound recordings made of me or my child at all Scouting activities,
and I hereby release the Boy Scouts of America, the local council,
the activity coordinators, and all employees, volunteers, related
parties, or other organizations associated with the activity from any
and all liability from such use and publication.
Por este conducto asigno y otorgo al concilio local y a Boy Scouts of
America el derecho y permiso para usar y publicar las fotografías/películas/
videocintas/representaciones electrónicas y grabaciones de sonido de mí
o mi hijo realizadas en todas las actividades Scouting, y por este medio
exonero a Boy Scouts of America, al concilio local, a los coordinadores
de la actividad y a todos los empleados, voluntarios, grupos involucrados
u otras organizaciones asociadas con la actividad, de cualquier y toda
responsabilidad por dicho uso y publicación.
I hereby authorize the reproduction, sale, copyright, exhibit,
broadcast, electronic storage, and/or distribution of said
photographs/film/videotapes/electronic representations and/
or sound recordings without limitation at the discretion of the
Boy Scouts of America, and I specifically waive any right to any
compensation I may have for any of the foregoing.
Por este conducto autorizo la reproducción, venta, derechos reservados,
exhibición, transmisión, almacenamiento electrónico y distribución de
dichas fotografías/películas/ videocintas/representaciones electrónicas
y grabaciones de sonido sin limitación a discreción de Boy Scouts
of America, y específicamente renuncio a cualquier derecho de
compensación alguna que pueda tener por cualquiera de lo anterior.
Yes/Sí
No/No
Page 1 of 2
PART B (continued on next page)
ADULTS AUTHORIZED TO TAKE YOUTH TO AND FROM EVENTS:
You must designate at least one adult. Please include a
telephone number.
ADULTOS AUTORIZADOS PARA TRANSPORTAR AL NIÑO HACIA Y DESDE
LOS EVENTOS:
Debe designar por lo menos a un adulto. Por favor incluya un número telefónico.
1. Name/Nombre___________________________________________________________________________Telephone/Teléfono _________________________
2. Name/Nombre___________________________________________________________________________Telephone/Teléfono_________________________
Adults NOT authorized to take youth to and from events/Adultos NO autorizados para transportar al niño hacia y desde los eventos:
1. Name/Nombre ___________________________________________________________________________Telephone/Teléfono_________________________
2. Name/Nombre ___________________________________________________________________________Telephone/Teléfono_________________________
Part B Full name: __________________________________________________________ DOB: ____________________
Parte B Nombre completo Fecha de nacimiento
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.
Entiendo que, si cualquier información que he/hemos proporcionado
es errónea, puede limitar o eliminar la oportunidad de participación en
cualquier evento o actividad.
If I am participating at Philmont, Philmont Training Center,
Northern Tier, Florida Sea Base, or the Summit Bechtel
Reserve: I have also read and understand the risk advisories
explained in Part D, including height and weight requirements
and restrictions, and understand that the participant will
not be allowed to participate in applicable high-adventure
programs if those requirements are not met. The participant
has permission to engage in all high-adventure activities
described, except as specifically noted by me or the healthcare provider. If the participant is under the age of 18, a parent
or guardian’s signature is required.
Si participo en Philmont, el Centro de Capacitación Philmont,
Northern Tier, la Base Marina de la Florida o Summit Bechtel Reserve:
También he leído y entiendo las advertencias de riesgo explicadas
en la Parte D, incluyendo los requisitos y restricciones de estatura y
peso, y entiendo que al participante no se le permitirá intervenir en
programas de aventura extrema si dichos requisitos no se cumplen.
El participante tiene permiso de intervenir en todas las actividades
de aventura extrema descritas, excepto aquellas específicamente
señaladas por mí o el proveedor de servicios médicos. Si el
participante es menor de 18 años, se requiere la firma de el padre/
madre o tutor.
Participant’s name/Nombre del participante______________________________________________________________________________________________
Date/Fecha
Participant’s signature/Firma del participante
Parent/guardian’s signature/Firma del padre o tutor
(if participant is under the age of 18/si el participante es menor de 18 años)
Second parent/guardian signature/Firma del otro padre o tutor
(if required; for example, CA/si se requiere; por ejemplo en CA)
Date/Fecha
Date/Fecha
This Annual Health and Medical Record is valid for 12 calendar months.
Este Registro Médico y de Salud Anual tiene vigencia por 12 meses calendario.
Page 2 of 2
680-001
2012 Printing
Rev. 9/2012
Part C/Parte C
Pre-participation Physical
Examen físico previo a la participación
Expedition/crew No.
Expedición/grupo no.:_______________________________
or staff position
o puesto fijo: ______________________________________
TO THE EXAMINING HEALTH CARE PROVIDER
PARA EL PROVEEDOR DE SERVICIOS DE SALUD QUE
REALICE EL RECONOCIMIENTO (Médicos certificados y
(Certified and licensed physicians [MD, DO], nurse practitioners, and
physician assistants)
You are being asked to certify that this individual has no contraindication
for participation in a Scouting experience as described in Part D. For
individuals who will be attending a high-adventure program, either unitbased or at one of the national high-adventure bases, please refer to
Part D for additional information.
Height (inches) Estatura (pulgadas)
Weight (pounds) Peso (libras)
Part C Full name: __________________________________________________________ DOB: ____________________
Parte C Nombre completo Fecha de nacimiento
Blood pressure Presión arterial
Pulso
If you exceed the maximum weight for height as explained on the next
page and your planned high-adventure activity will take you more than
30 minutes away from an emergency vehicle/accessible roadway, you
will not be allowed to participate. At the discretion of the medical
advisers of the event and/or camp, participation of an individual
exceeding the maximum weight for height may be allowed if the body
fat percentage measured by the health care provider is determined
to be 20 percent or less for a female or 15 percent or less for a male.
(Philmont requires a hydrostatic weighing or DXA test to be used for
this determination.) Please call the event leader and/or camp if you
have any questions. Enforcing the height/weight guidelines is strongly
encouraged for all other events.
Examiner: Please fill in the information.
Examinador: Favor de completar la información.
Normal
Porcentaje de grasa corporal (opcional)
Yes/Sí
No/No
Si usted excede el peso máximo para su estatura tal como se explica
en la siguiente página y su actividad de aventura extrema planeada
le llevará a más de 30 minutos de distancia de una vía con acceso
para un vehículo de emergencia, usted no podrá participar. A juicio
de los consejeros médicos del evento o campamento, la participación
de un individuo que exceda el peso máximo para su estatura puede
permitirse si el porcentaje de grasa corporal medida por el proveedor
de servicios de salud determina que es 20 por ciento o menos para una
mujer o 15 por ciento o menos para un hombre. (Philmont requiere que
se use una prueba de peso hidrostático o de densitometría ósea para
determinarlo). Por favor llame al líder del evento o del campamento si
tiene preguntas. El cumplimiento de los lineamientos de estatura y peso
se recomienda encarecidamente para todos los demás eventos.
Range of Mobility
Rango de movilidad
Eyes
Knees (both)
Ears
Ankles (both)
Nose
Spine
Ojos
Cumple con los límites
de estatura/peso
Percent body fat (optional)
Explique cualquier anomalía
Meets height/
weight limits
Máximo peso para la estatura
Abnormal Explain Any Abnormalities
Anormal
Maximum weight for height
Pulse Normal
licenciados, enfermeras profesionales y asistentes médicos)
Se les está solicitando que certifiquen que este individuo no tiene
contraindicación para participar en una experiencia Scouting tal como
se describe en la Parte D. Para individuos que estarán participando en
un programa de aventura extrema, ya sea en la unidad o en una de las
bases nacionales de aventura extrema, por favor consulte la Parte D para
información adicional.
Incorrect:
Correct:
IncorrectoCorrecto
Normal
Normal
Abnormal Explain Any Abnormalities
Anormal
Explique cualquier anomalía
Rodillas (ambas)
Oídos
Tobillos (ambos)
Nariz
Espina
Throat
Garganta
Lungs
Pulmones
Neurological
Other
Yes
Otro
Neurológico
Sí
Heart
Personal or family
history of heart disease
Abdomen
Medical equipment
(i.e., CPAP, oxygen)
Genitalia/hernia
Contacts
Skin
Dentures
Emotional
adjustment
Braces
Corazón
No
Explain
Explique
Historial personal o familiar
de enfermedad cardíaca
Abdomen
Equipo médico (por
ejemplo, CPAP, oxígeno)
Genitales/hernia
Lentes de contacto
Piel
Dentaduras
Tratamientos de
ortodoncia
Ajuste emocional
Tuberculosis (TB) skin test (if required by your state for BSA camp staff):
Negative/Negativo Prueba de Tuberculosis (TB) (si lo requiere su estado para personal del campamento BSA)
Allergies/Alergias:
No
No/No�
Positive/Positivo
Yes/Sí (explain to what agent, type of reaction, treatment/explique a qué agente, tipo de reacción, tratamiento):
___________________________________________________________________________________________________________________________________
Medical restrictions to participate/Restricciones médicas para participar:
No/No
Yes/Sí (explain/explique):
___________________________________________________________________________________________________________________________________
Page 1 of 2
PART C (continued on next page)
EXAMINER’S CERTIFICATION
CERTIFICACIÓN
DEL EXAMINADOR
Height
(inches)
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 above):
Certifico que he revisado el historial médico, examinado a esta persona
y no encuentro contradicciones para su participación en una experiencia
Scouting. Este participante (con las restricciones descritas anteriormente):
TrueFalse
CiertoFalso
Part C Full name: __________________________________________________________ DOB: ____________________
Parte C Nombre completo Fecha de nacimiento
Incorrect:
Correct:
IncorrectoCorrecto
60
97-138
139-166
166
61
101-143
144-172
172
62
104-148
149-178
178
63
107-152
153-183
183
64
111-157
158-189
189
Excepción
permitida
Aceptación
máxima
65
114-162
163-195
195
Cumple con los requisitos de estatura/peso
66
118-167
168-201
201
oes not have uncontrolled heart disease,
D
asthma, or hypertension
67
121-172
173-207
207
68
125-178
179-214
214
69
129-185
186-220
220
70
132-188
189-226
226
71
136-194
195-233
233
72
140-199
200-239
239
No ha tenido una lesión ortopédica, problemas
musculoesqueléticos o cirugía ortopédica en los últimos
seis meses o posee una carta de autorización por parte
de su cirujano ortopédico o médico
Maximum
Acceptance
Meets height/weight requirements
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
Peso recomendado
(libras)
Allowable
Exception
No tiene cardiopatía, asma o hipertensión incontrolados
Estatura
(pulgadas)
Recommended
Weight (lbs)
Has no uncontrolled psychiatric disorders
73
144-205
206-246
246
Has had no seizures in the last year
74
148-210
211-252
252
Does not have poorly controlled diabetes
75
152-216
217-260
260
If less than 18 years of age and planning to
scuba dive, does not have diabetes, asthma,
or seizures
76
156-222
223-267
267
77
160-228
229-274
274
78
164-234
235-281
281
79 & over
170-240
241-295
295
No tiene trastornos psiquiátricos incontrolados
No ha tenido convulsiones en el último año
No tiene diabetes mal controlada
Si tiene menos de 18 años de edad y piensa realizar
buceo, no tiene diabetes, asma o convulsiones
I have reviewed Part D for high-adventure
activities.
He revisado la Parte D para actividades de aventura
extrema.
Provider printed name
Nombre del proveedor ________________________________________________
Address
This table is based on the revised Dietary Guidelines for Americans from the
U.S. Dept. of Agriculture and the Dept. of Health & Human Services.
Esta tabla está basada en los Lineamientos dietéticos para estadounidenses del
Departamento de Agricultura de los EE.UU. y del Departamento de Salud y
Servicios Humanos.
Domicilio ____________________________________________________________
DO NOT WRITE IN THIS BOX
NO ESCRIBA EN ESTE RECUADRO
City, state, zip
Ciudad, estado, código postal _________________________________________
Office phone
REVIEW FOR CAMP OR SPECIAL ACTIVITY/REVISIÓN PARA CAMPAMENTO O
ACTIVIDAD ESPECIAL
Date
Reviewed by
Revisado por ______________________________________________________________
Teléfono del consultorio _______________________________________________
Fecha ______________________________________________________________
Examiner signature in the box below.
Firma del examinador en el recuadro de abajo.
Date
Fecha ____________________________________________________________________
Further approval required Se requiere aprobación adicional
Yes Sí
No
No
Reason
Razón_____________________________________________________________________
Approved by
Aprobado por______________________________________________________________
Date
Fecha ____________________________________________________________________
Click here for more information regarding high-adventure outings or go to www.scouting.org/filestore/HealthSafety/pdf/part_d.pdf.
Haga clic aquí para obtener más información sobre las excursiones de aventura extrema o visite www.scouting.org/filestore/HealthSafety/pdf/
part_d.pdf.
Page 2 of 2
680-001
2012 Printing
Rev. 9/2012
PLANNED EARLY DEPARTURES FROM CAMP
Any Scout who plans to depart camp (to play ball for example) at any other time than Saturday
morning, MUST HAVE A SIGNED RELEASE BY THEIR CUSTODIAL PARENT BEFORE
CAMP. This release (see below) must identify the date and the time of departure and the name
of the adult that will be picking up the Scout. This release MUST be presented to the CAMP
DIRECTOR on Sunday when the Scout Leader checks in at the Camp Office. When the adult
arrives at Camp to pick up the Scout they will be asked to provide identification.
The BOY SCOUTS OF AMERICA and the JAYHAWK AREA COUNCIL recognize the possibility
that a non-custodial parent or another adult could abduct a child while they are in attendance at
camp. This policy is designed to prevent such an occurrence and is an added safety for you and
your child.
Please, do not ask for an exception.
Note:
All visitors MUST check in at the Camp Office immediately upon arrival at Camp.
*Please turn in completed photocopy of this form.
Thank You
– RELEASE –
PLANNED EARLY DEPARTURES FROM CAMP
Scout’s Name______________________________________________ Troop No.__________
Date of Planned Departure_____________________ Time:_______
Date of Planned Return________________________ Time:_______
Reason for Departure: ________________________________________________________
Name of Adult Picking up Scout: _________________________________________________
Signature, Parent or Guardian:___________________________________________________
Home Phone:_____________________________ Work Phone:________________________
Witnessed by Camp Leader:______________________________________ Date:_________
Note to Camp Leaders: Please duplicate this page and hand it out to the parents of Scouts
who will be attending camp.
- A-4 -
Camp Jayhawk Payment Form for Visitor Meals
1. All payments for visitor meals should be made at check-in using this form
or submitted online during online registration. Please list those you are
paying for below. Cost of each visitor meal is $7.
2. Guests that are eating with us are required to check-in at the camp office.
Each person will receive a camp wristband that serves as his or her meal
ticket and permission to be on camp property. This is for all guest meals
except for family night.
3. Troops that have paid for Friday family night visitor meals will be handed a
packet with wristbands at the Friday leaders meeting. Remember,
wristbands are your meal tickets.
4. Visitors should make every effort to turn in wristbands when they check
out of camp.
Please list the name of each person that will be attending a guest meal:
Name
Name
1.
2.
3.
4.
5.
6.
7.
8.
9.
10
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
21.
22.
23.
24.
# of guest meals _____ @ $7 each = $________
Please pay amount due at camp office during check-in.
-A-5-

Leader Guide - Jayhawk Area Council

Transcripción

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Dear Parents, It is hard to believe that another school year has passed!