Dear Staff Member - Heart of America Council

Transcripción

Theodore Naish
Scout Reservation
2014 Staff Guide
“A Tradition of Adventure”
QUICK REFERENCE
Heart of America Council, BSA
Program & Camping Department
10210 Holmes Road
Kansas City, MO 64131-4212
Ph: 816-569-4930
Fax: 816-569-4981
Web: www.hoac-bsa.org
Bob Euler
Reservation Commissioner
C: 913-306-2178
Email: [email protected]
Raul Salmon
Central Camp Director
H: 816-222-4878
C: 816-419-6174
Theodore Naish Scout Reservation
1100 Martinek Lane
Kansas City, KS 66111
Ph: 913-422-1035
Fax: 913-441-6920
Phil Helt
Central Camp Program Director
C: 816-686-9392
Cortland Bolles
Naish Reservation Director
W: 816-569-4955
Judy Tuckness
Cub World Director
C: 913-244-9653
Tanner Couvelha
Naish Reservation Ranger
C: 913-683-4748
Mike Hanus
Cub World Program Director
C: 913-515-6054
Bob Miller
Naish Lead Maintenance Commissioner
C: 913-685-3729
2 weeks after receiving this packet, please return
the following to the Council Service Center:
 Letter of Employment
 Code of Conduct
 Automobile Regulations
 Federal W-4
 Kansas W-4
 Federal I-9**
 ACH (if desired)
Calendar of Important Dates
March 1, 2014: Central Camp Directors and
Counselors Work Meeting #1(TENTATIVE)
March 11, 2014: Boy Scout Leaders Orientation #1
(LDS Units Only)
March 12, 2014: Boy Scout Leaders Orientation #2 When you arrive for Staff Week you must bring:
April 8, 2014: Webelos Leaders Orientation #1
 All forms you have not turned in previously
 Supporting original documents for I-9**
 Annual Health and Medical Record, signed
April 25 – 27, 2014: OA Spring Induction #1
by an MD or DO
April 29, 2014: Staff Parent Orientation @ Naish
 Proof of completion for the following
May 9 – 11, 2014: OA Spring Induction #2
trainings:
May 10 – 16, 2014: National Camping School
o Youth Protection Training
May 13, 2014: Bear Camp Leaders Orientation #1
o Hazardous Weather Training
May 19, 2014: Bear Camp Leaders Orientation #2
o Unlawful Harassment Prevention
May 25 – 31, 2014: Naish Staffs Work Week
Training**
August 3, 2014: Camp Take Down & Staff Banquet
**If completed in 2013, you will not need to redo in 2014.
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INDEX
Naish Scout Reservation Mission
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Page 5
HOAC Resident Camp Sessions
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Page 6
General Information
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Page 7
Living Quarters & Personal Possessions
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Page 13
Personal Staff Interaction & Conduct
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Page 14
Camp Staff Packing List
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Page 15
Special Requests for Time Off
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Page 16
Rules and Regulations
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Page 16
Alcohol, Tobacco, Controlled Substance
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Page 17
Discipline Procedures
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Page 17
Youth Protection
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Page 17
Camp Counselor/ Director Job Overview
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Page 19
Instructor Job Overview
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Page 20
How to Make Your Program Area Popular
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Page 20
Emergency Procedures
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Page 21
APPENDIX
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Page 23
Authorization Agreement for Automatic Deposits
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Page 25
Federal Form W-4
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Page 27
Employment Eligibility Verification (I-9)
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Page 29
Kansas W-4
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Page 31
Camp Staff Code of Conduct
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Page 33
Automobile Regulations
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Page 35
Annual Health and Medical Record
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Page 37
Authorization for Administering of Medications
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Page 43
Time Off Form
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Page 45
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Dear Staff Member:
Congratulations on your selection as a member of the 2014 Theodore Naish Scout Reservation Summer
Camp Staff. We are pleased to have you as part of the team. Please be conscious of your appearance,
manners, language and demeanor at all times. Let the Scout Oath and Law serve as your guides through
this new adventure, and perform your duties to the best of your ability with genuine “Scout Spirit.”
As a camp staff member at Naish Scout Reservation, high expectations come with the territory. Campers,
leaders, fellow staff, camp leadership, and you should have high expectations of yourself and everyone
you work with as a member of this staff. Excellence has been a part of our camp for almost nine decades
and will continue to be for many more decades to come. Meeting those high expectations through
excellent customer service is the best way to ensure your success as a camp staff member at Naish Scout
Reservation.
The following pages contain important information designed to make this a success and rewarding
experience for you and the Scouts who will look up to you this summer. Read them all carefully, and bring
this manual with you to camp.
Please return one (1) signed copy of the “Letter of Agreement,” Automobile Regulations, Code of
Conduct, Authorization Agreement for Automatic Deposits (if desired), Federal W-4, Federal I-9**, and
Kansas W-4 to the Council Service Center within two (2) weeks of receiving them.
**If you completed the I-9 in 2013, you will not need to redo for 2014
Again, congratulations of being selected. Welcome and good luck as you assume your responsibilities as a
member of the Theodore Naish Scout Reservation Camp Staff.
Sincerely,
Cortland Bolles
Reservation Director
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THEODORE NAISH SCOUT RESERVATION
MISSION STATEMENT
The mission of the Theodore Naish Scout Reservation is to provide an opportunity for Cub Scout packs, Boy
Scout troops, Varsity teams, and Venturing crews, primarily from the Heart of America Council, to have fun,
learn skills, and practice Scouting programs in the outdoors under their own leadership. The philosophy of
the camp staff is a total commitment to serving our customers (Scouts, Venturers and their adult leaders) to
the best of our ability. In pursuit of this meaningful goal, we pledge to strive to incorporate the following
things into every Naish Scout Reservation activity:
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Teaching & Coaching: Traditional Scouting skills will be taught to all those in need of instruction.
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Values: All camp staff members are committed to being good role models; always exemplifying
the Scout Oath and Law.
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Fun: We will deliver fun filled camp-wide programs that will be enjoyed and remembered by
every youth that attends camp.
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Quality Program: An emphasis on quality and good health, with careful attention paid to program
content, menu selections, food sales at the trading post, and physical activities will be a part of
everything we do.
In order to live up to this commitment to our customers, the Theodore Naish Scout Reservation will feature a
quality, mature, energetic, and enthusiastic staff to provide activities that will lead Cub Scouts into the Boy
Scout program, and help Scouts on the Trail to Eagle Scout rank. Our commitment is to have the best
Venturing Camp Program in the nation.
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GENERAL INFORMATION
1.
Staff Letter of Employment/Agreement & Required Forms: All paid staff members must have signed
a Letter of Employment, as well as completed both an Employee’s Withholding Allowance Certificate
(Form W-4) and a Kansas W-4 prior to the beginning of the summer to enable proper distribution of
paychecks. Additionally, every staff member – paid or volunteer – must also complete and sign a
government I-9 form**, Automobile Regulation form, completed Annual Health and Medical Record,
and a Council Code of Conduct form. These forms can be found in the Appendix section of this Staff
Guide. They will be kept on file at the reservation. **If form was completed in 2013, you do not have to redo for 2014
2. Boy Scouts of America Registration: All staff members of the Theodore Naish Scout Reservation must
be registered with the Boy Scouts of America. If you are not currently registered with the Boy Scouts
of America, you will be required to complete an application and pay the appropriate fees prior to
the start of camp.
3. Payroll: The forms noted above are important because the Heart of America Council cannot pay you
until you have completed all of them. Payroll dates for the summer are as follows:
Pay Day
Includes Time Through
Number of Days In
Payroll*
Friday, June 13, 2014
May 31, 2014
7 days
Monday, June 30, 2014
June 14, 2014
14 days
Tuesday, July 15, 2014
June 28, 2014
14 days
Thursday, July 31, 2014
July 19, 2014
21 days
Monday, August 4, 2014
August 3, 2014
15 days
*Potential estimate only. Numbers do not take into consideration days-off from camp.
Electronic deposit of payroll is available, and highly encouraged. See the ACH form in the Appendix.
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4. Staff Week: Staff Week is a very important part of our camp program. Besides orienting staff
members to summer camp programs, procedures, and teaching methods, as well as preparing the merit
badge, outpost, and other program areas for use, the camp itself must be prepared to receive the
Scouts which will soon follow. Many physical tasks such as campsite preparation and building clean up
and set up must be completed. At times, you will be expected to work in other parts of the camp
besides the specific area you are assigned to. Plan on being at camp during this time unless you
are a Counselor-In-Training.
5. Mail: Mail can be sent to you at the following address:
(Your Name)
Theodore Naish Scout Reservation
Summer Camp Staff (Cub World or Central Camp)
1100 Martinek Lane
Kansas City, KS 66111
6. Visitors: Visitors and family members are always welcome to visit on family night and for opening
and closing campfires with prior permission obtained from the Reservation/Camp Director. You
should plan to meet your visitors at the Reservation Office or Cub World Office.
The staff area is only for 2014 Camp Staff Members, their families, and approved guests. Approval
of guests will be made by the Camp Director or Reservation Director.
7. Religious Services: The 12th point of the Scout Law is “reverent.” Your participation in religious and
vesper services is required. Opportunities may exist to work on religious awards while on camp staff.
Also, you should respect the rights and beliefs of others while serving on staff.
8. Dining Hall/Cub World Shelter: All staff members will be at all meals on time and properly uniformed.
The staff should be easily visible to the campers in the dining hall. Proper table manners, food
distribution, and courtesy are marks of a mature staff member. Staff yells or songs may be given after
the meal as indicated by the Program Director or his designee. Staff members may periodically be
given other responsibilities regarding the dining hall. These will be covered in full during staff week
training. Any special meal requests for dietary needs must be filled out prior to camp and
discussed with the dining hall director.
9. Punctuality: As a staff member, you are expected to be in attendance at, on time to, and in proper
uniform for, all activities in which the camp staff is involved, especially reveille and retreat (flag
ceremonies), meals and campfire programs. Any exceptions must be approved by the Program
Director. There is no reason for you to be late if you plan ahead. Remember, we set the example for
the entire camp.
10. Camper Check-In & Check-Out Duties: Each staff member will be assigned a specific function, such as
swim checks, parking, and campsite hosts, to be carried out as units are checking in and out of camp.
Your cooperation completing those tasks assigned to you as quickly and efficiently as possible is
expected.
11. Staff Use of Program Areas & Equipment: If your schedule permits, and they are not in use by
campers, you are welcome to use program areas and camp equipment after obtaining prior approval
from the director in charge of them, the Program Director, and the Camp Director. Any fees
associated with their use must also be paid in advance, i.e., ammunition for the guns at the range.
Remember that the campers come first!
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12. Staff Uniforms: The Boy Scouts of America is a uniformed organization. Always wearing the proper
uniform is a job related responsibility. The Venturing uniform is expected for Bear and Venturing Camp
Staff. You will be provided with two staff t-shirts. Additional t-shirts may be purchased. Please have
enough additional parts of the uniforms described below to insure your ability to be in correct uniforms
at all times. A proper uniform will identify you as a member of the camp staff team. In addition, the
Staff Nametag will be worn at all times. Our designated uniforms for this summer are as follows:
A. Official Field Uniform (commonly called “Class A”)
The Official Field Uniform consists of an official Boy Scout or Venturing Uniform Shirt, Trousers or
Shorts, Scout or Venturing Belt (web or leather), Scout or Venturing Socks (ankle length, crew length,
or knee length). It is not necessary to wear a merit badge sash, neckerchief, or hat to be in correct
“Class A” uniform. While it is always acceptable to wear the “Class A” uniform, the camp staff
uniform (“Class B”) is the standard for all activities except Sunday religious services, formal flag
retreats, and times indicated by the Program Director.
B.
Camp Staff Uniform (commonly called “Class B”)
Official Boy Scout or Venturing shorts or trousers, Scout belt (web or leather), socks and “Class B”
staff t-shirt. The “Class B” is to be worn with belt, socks adjusted appropriately and t-shirt tucked
in. This is the expected uniform for all times other than when “Class A” is required. No tie-dyed,
damaged, or inappropriate shirts are allowed.
C. NOTES
 All Naish Staff who are members of OA and/or MOS should wear their adornments at
all appropriate times.
 White socks may not be worn with Scout or Venturing shorts.
 Field uniforms must be clean and shirts must be tucked in and have a minimum of a
Council patch, American flag, and lodge patch (as appropriate). These patches must be
in the proper location and sewn on properly and neatly.
 Activity uniform shirts must be clean and tucked in.
 Though some Venturing Crews allow exceptions to uniform parts, the Theodore Naish
Camp Staff requires that your uniform consists entirely of OFFICIAL uniform parts in
Bear and Venturing Camp.
 For the first program days of the session, all members of the staff must wear 2014 staff
shirts when in the activity uniform. Other than the first day, any Naish summer camp
Scout staff shirt may be worn.
 Some exceptions to the above uniforming are allowed with knowledge and permission
of your Program Director. Outpost Staff is frequently allowed to wear jeans and Pool
Staff to wear swim suits (no racing or Speedos). Female staff members must wear onepiece swim suits.
 Only Boy Scout and Venturing hats may be worn.
 No open-toed shoes may be worn anywhere on the reservation except the pool and the
water park.
 BSA Dress Code will be observed at all times. No sleeveless attire. Modesty is a must.
13. Laundry Services: Clothes cleaning equipment is provided for staff. Staff will need to provide their
own detergent and dryer sheets. Be sure to label all your clothing items for proper identification. Help
keep this area clean. It is provided as a courtesy to you.
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14. Personal Belongings: Clearly label all personal items that you bring to camp. Be careful to whom
you loan your personal belongings. Be courteous – do not use, touch, borrow, eat, etc., other people’s
belongings without their consent. Thieves and vandals will be dealt with swiftly and decisively.
15. Staff Recreation Area (Central Camp Staff): Please take care of the area, and keep it clean. Scouts
are clean, but camp staff members will be cleaner.
16. Scout Advancement by Camp Staff Members: If your schedule permits, you may have an opportunity
to work on advancement during your “off time” or “free time.” The Program Director should be
informed prior to your starting work on any merit badge or Venturing award, so that he can work
directly with the director or counselor in charge of that program area to facilitate your request.
Remember that your first priority is to help the Scouts in camp. Personal advancement is secondary
during summer camp operation.
17. Staff Use of Program Areas & Equipment: If your schedule permits, and they are not in use by
campers, you are welcome to use program areas and camp equipment after obtaining prior approval
from the director in charge of them, the Program Director, and the Camp Director. Any fees
associated with their use must also be paid in advance, i.e., ammunition for the guns at the range.
Remember that the campers come first!
18. Trading Post: The Trading Post is operated on a cash basis for everyone in camp. No credit is
allowed! Every item for sale in the trading post is sold at retail price. Camp staff members, with the
exception of office and trading post personnel, are not to be behind the trading post counter or in the
stock room. All items for sale at camp are handled directly through the trading post. Do not bring
items to sell yourself. Selling materials or items to campers, other staff members, or leaders is not in
accordance with the Boy Scouts of America Polices. Please reference the policy in the appendix. No
staff is allowed in the storage room without permission from the Business Manager. Violation of these
rules is grounds for automatic termination.
Staff members will receive 20% on items (except OA merchandise) purchased at the Trading Post.
The discount is only available to staff members during summer camp operations. They cannot use
their discount during off-season Trading Post hours.
19. Firearms & Weapons: Firearms, archery equipment, and other weapons are to be used only in
assigned program areas under proper supervision. Personal firearms, sheath knives, archery
equipment, blow guns, sling shots, paint guns and other weapons are not permitted at camp. This is
grounds for automatic termination.
20. Kitchen: The kitchen and commissary are off limits to all staff except for the food service staff, the
Business Manager, Reservation Director, Camp Director, Program Director, lead commissioners, trading
post manager, assigned trading post staff and rangers. There are no exceptions to this policy.
21. Keys: Keys will be issued during staff week to those directors that need keys to their areas, and they
are responsible for them. Keys are not to be duplicated. If keys are found to have been duplicated,
the duplicator(s) will be required to pay to have the entire reservation re-keyed. Keys must be
returned at the end of camp by the staff they were issued to before they will receive their final
paychecks. Lost keys should be immediately reported to the Program Director and Camp Director.
Please reference the key policy in the appendix.
22. Automobiles: A completed automobile regulation form, signed by your parents, must be presented to
the Reservation Director or the Camp Director or their designee upon your arrival at camp. This will be
kept on file for reference during the summer. This form is for both drivers and passengers. Specific
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questions, requiring specific answers, are listed on this form. Only the Reservation or Camp Director
can check you in and out of camp, and they will check your automobile regulation form for the
approved types of usage of your vehicle. Automobiles are not needed at camp, and the loaning of
a vehicle to one staff member by another is not permitted unless specifically noted on your form.
Vehicles will not be parked in staff village behind the dining hall or next to the dining hall. They
will be parked in the staff parking lot. Violation will result in loss of all personal automobile
privileges for the balance of the summer.
THE HEART OF AMERICA COUNCIL IS NOT RESPONSIBLE FOR THE LOSS OF, OR DAMAGE CAUSED TO,
ANY VEHICLE BY FIRE, STORM, AND THEFT OR VANDALISM. THEY ARE ALSO NOT RESPONSIBLE FOR ANY
LOSS OR DAMAGE TO ANY ARTICLES LEFT IN VEHICLES.
23. Staff Fun Nights Off Reservation: Throughout the summer, there will be opportunities in the evening
for the staff to venture off reservation to partake in staff-wide activities. Previous events include going
to a T-Bones Game or Galactic Bowling. Similarly, with previous permission of the Program Director
and Camp Director, a program area staff may have a “Night Out” and go into town for dinner. In both
cases, every staff member attending must have a signed Automobile Regulations Form on file. Staff can
only seek permission for a Night Out when it does conflict with their regular camp duties.
24. Manners, Grooming, Language: We expect the best! If you have or need to be reminded or
corrected, your maturity is in question. Your hair should be neat, clean, and trimmed. Your
appearance should be a shining example to the Scouts that attend camp. Any unusual modifications
during summer camp will not be tolerated, including, but not limited to, piercings and tattoos. Again,
remember that we set the example for the entire camp. Additional appearance guidelines may be set
forth by the Program Director and Camp Director at their discretion. Staff will avoid vulgar and
inappropriate words or slang, such as profanity
25. Order of the Arrow: The Order of the Arrow is a part of the Theodore Naish Scout Reservation Boy
Scout residence camp program. Arrowmen who wish to be a part of any Order of the Arrow
ceremony may do so only after completion of camp staff responsibilities. The Program Director is the
only person that can excuse an Arrowman from his assigned camp responsibilities.
26. Equal Opportunity Employer: The Heart of America Council does not discriminate on the basis of race,
color, national origin, sex, religion, age, or handicapped status in the provision of services or
employment.
27. Social Media: Social media, such as Facebook, Twitter, and YouTube, are all popular forms of
communication. However, camp staff members are representatives of the BSA and must be especially
careful how they use these and other forms of communication. Under no circumstance should you discuss
or transmit personal or inappropriate information with a camper, leader, or another staff member.
Not only can these forms of communication be misinterpreted, they can also be widely dispersed. It is
even possible that such postings will resurface many years later, resulting in embarrassment.
28. Informing the parents of minors: Situations may occur at camp that may require discipline of a staff
member, up to and including termination of employment. Parent or guardians of staff members under
the age of 18 will be notified promptly of any disciplinary action that involves more than a written
warning. Parent or guardians of staff members will also be notified promptly of the dismissal of a
staff member under the age of 18.
The camp will investigate all good faith complaints of misconduct of a staff member. In the event of
an ongoing investigation regarding the misconduct of a staff member, parents of all campers and staff
members involved in the investigation will be notified at an appropriate time. The Reservation Director
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or Camp Director will reasonably and in good faith determine when such notification is appropriate,
but the time for notification may vary depending on the unique facts and circumstances of the incident
of alleged misconduct. The results of an investigation are generally confidential. When appropriate,
parents or guardians of campers and staff members involved in an investigation will be notified of the
results of the investigation.
29. Staff Training and Preparation: Having a “trained” camp staff is a part of our obligation toward the
Boy Scout campers and leaders who will look to us this summer. Staff Training consists of the following:
a. Pre-Camp Preparation
Some training occurs before you even arrive at camp and is a part of your personal
preparation for you assignment. Bring with you to camp, evidence of completion of the
following on-line courses available at www.myscouting.org (BSA membership # is required)
1. Youth Protection Training
2. Hazardous Weather Training
3. Unlawful Harassment Prevention Training**
**If training was completed in 2013, you will not have to redo for 2014.
b. Adult Staff (18 & over) must be trained for your position.
Those registered as a scoutmaster or assistant scoutmaster must have:
2. Scoutmaster / Assistant Scoutmaster Specific
3. Intro to Outdoor Leader Skills (not available online)
Those who are registered as troop committee members must have:
2. Troop Committee Challenge
c. If you are instructing a merit badge or supervising that instructor, you need to review
the current requirements before you arrive at camp. You can go to www.usscouts.org
for updated requirements and worksheets to assist on earning these badges.
d. Staff Week Preparation
Staff Orientation Week for Central and Bear Camp Staff is May 25 – 31, 2014.
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LIVING QUARTERS & PERSONAL POSSESSIONS
Adequate living quarters are provided for each staff member. It is agreed that they will be kept in a
clean, desirable condition. You will be assigned to a cabin, and a mattress and bed will be checked out to
you. Staff members are personally responsible for damage to, or the defacement of, their living quarters
and staff village. The Reservation Director, Camp Director, Program Director, Business Manager, and
Ranger will handle the checking in and out of staff members to cabins, and will periodically inspect them
for damages over and above the normal wear and tear. Staff members are not to change living
quarters without prior approval being given, and a cabin inspection being done, by the Reservation
Director, Camp Director or Program Director. Repair costs for damages to a staff cabin may be assessed
to some or all of individuals assigned to the cabin.
PLEASE NOTE: Camp staff recreational areas, cabins, personal camp boxes and cars, and storage
facilities within camp staff program areas may, from time to time, be subject to unannounced inspection by
the Reservation Director or Camp Director, or their designee, and the ranger. The appearance of your
living area is important to maintaining a positive working environment and is expected to be in good
presentation at all times.
Due to electrical expenses and fire hazards, only approved electrical equipment will be allowed in the
staff cabins. One television, one small stereo and/or radio, one clock, and two fans are permitted per
cabin. Refrigerators, air conditioners, hot plates, musical instruments, and other related electrical
appliances are not approved. No exterior antennas are allowed. Finally, Scouts should be conservation
minded. Please turn off the lights, fans, and other electrical equipment when you are not in your cabin.
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No painting or marking, inside or outside, on the staff cabins and other structures.
No campers or leaders are allowed in the staff area.
No overnight guests are allowed in staff areas.
Staff cabins, recreation areas, and latrines must be kept neat and clean. Remember that the 11th
point of the Scout Law is a Scout is clean. All staff (to be coordinated by the Program Director) will
share responsibilities for cleaning the staff showers, latrines, and recreation areas.
For security reasons, please leave valuable items or “collectibles” at home.
Personal vehicles are not permitted in the staff area. The only vehicles allowed inside the village
are camp vehicles for maintenance purposes. To unload prior to camp, and load at the end, staff
members may park just outside of the area. The remainder of the time, vehicles are to be kept in
the designated staff camp parking lot. Do not park behind the dining hall.
Staff members are permitted to bring mountain bikes to camp. Helmets are required for all riders.
Carpet is permitted, but must be removed at the end of camp. Remember that anything you bring,
you take home.
Camp (seasonal) staff members are not allowed to bring pets to camp.
Doors to cabins may not be locked.
Tampering with smoke alarms in cabins will be grounds for dismissal.
Only equipment and furniture approved by the Camp Director may be kept in the cabin. Furniture
affixed to the floor must be left in place. No exterior antennas or weight lifting equipment is
permitted.
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PERSONAL STAFF INTERACTION AND CONDUCT
Staff Areas:
You will be given a personal tour of staff living quarters upon your check-in. During this time you will be
shown the boundaries for the male staff area, female staff area, and common ground areas.
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Male staff members only in the male housing.
Female staff members only in the female housing.
All staff members are allowed in the common area.
All staff members must wear appropriate dress outside cabins and shower areas. (The wearing of
only a towel or undergarments is not acceptable and will be grounds for disciplinary action and/or
termination if conduct repeated)
When changing at any time, close doors and pull curtains closed.
All staff members must be in the staff area and all overhead lights and other items that may
disturb your cabin mates and neighbors must be turned off at 10:00 p.m.
No staff members allowed in the common area after 10:30 p.m. (Using the bathrooms is
acceptable)
All staff must be in their own cabins and all lights and other entertainment devices must be turned
off at 11:00 p.m.
Staff and Program Areas
 Public and private displays of affection between staff members are in violation of the National
Youth Protection Policies and will not be tolerated while you are on the camp property or while on
an approved camp-wide outing.
 When in the company of a staff member of the opposite sex you need to not only follow Youth
Protection Guidelines, you must also be in the company of another staff member or in public view.
Sexual misconduct or sexual relations amongst/ between staff members is not tolerated and will
result in immediate dismissal.
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CAMP STAFF PACKING LIST
Items you will need or may want to bring with you to camp:
 Uniform Boy Scout Shorts (2 or 3 pair)
 Short Sleeved Boy Scout Shirt (1 or 2) with proper insignias
 Uniform Belt with Scout Buckle (web or leather)
 Scout HOAC “Staff” T-Shirts
 Uniform Socks (4 to 6 pair)
 Casual Shoes or Hiking Boots
 Underwear
 Bedding (sheets, pillow, blanket. NOTE: Staff Cabins feature twin sized beds.)
 Rain Gear
 Swim Trunks
 Work Clothes
 Personal Toilet Articles
 Pens and Pencils, Paper or Notebook
 Water Bottle
 Flashlight
Other Suggested Miscellaneous Equipment that could be helpful are:
 Pajamas
 Cup
 Small Rug
 Radio
 Lamp
 Work Gloves
 Chair
 Sewing Kit
 Watch or Clock
 Sunglasses
 Camera/Film
 Fan
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SPECIAL REQUESTS FOR TIME OFF
Employee requests for time off will be accepted during your interview, and considered and decided
upon in a timely manner. Full time staff members will be given the opportunity to take three days of
vacation without pay. Whether or not these are granted will depend primarily upon the scheduled
operation of the camp and its current available manpower status. All time off requests should be
submitted prior to Staff Week (see appendix for time off form). All time off is unpaid. Special
arrangements may be made through the reservation/Camp Director for leave without pay and time off for
emergencies, and trips to Philmont, Bartle, National Jamboree, NOAC, etc.
Staff members must check out before leaving and check in upon returning to camp with the Camp Director.
Violation of this rule may result in, but is not limited to, a loss of additional time off request privilege. A
second violation may result in the termination of employment at the discretion of the Reservation Director.
In addition to checking in and out with the appropriate people, staff members are to also log in and out of
camp using the camp staff arrival and departure cards kept in the office.
RULES AND REGULATIONS
We are an example in the lives of the young men and women that participate in the programs our camp
has to offer. Remember that as a Scout, and now as a camp staff member, you are expected to live the
Scout Oath and Law, and conduct yourselves in an exemplary manner, on or off the reservation, in or out
of uniform.
Examples of unacceptable violations of this code of conduct include, but are not limited to, the following:
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Violation of the law, including traffic violations.
Gross misconduct or conduct not conforming to the Scout Oath and Law.
Fighting, insubordination, and/or willful damage to Boy Scouts of America property.
Soliciting funds, the sale of property, or the use of BSA facilities for personal gain.
Possessing, selling, or being under the influence of alcoholic beverages on the reservation or in
uniform anywhere.
Possessing, selling or using unprescribed drugs, or misusing prescribed medication.
Stealing or having unreported knowledge of a theft that occurred.
Possessing or having unreported knowledge of someone possessing protected birds of prey parts,
feathers, or claws at camp.
Unauthorized use, or the duplication, of camp keys.
Leaving the reservation without the approval of the Reservation Director, Camp Director, Program
Director, or Ranger.
The possession or use of fireworks by seasonal staff members at camp is prohibited.
Misuse of the reservation radio system.
Using profane language.
Showing up late to your program area or not being at the program.
Violation of any of the above rules can result in immediate dismissal.
Negligence regarding any of the following items may result in the termination of your contract. All
violations will be noted in the individual personnel files.
All above rules and regulations remain in place while you are on an approved Scout outing.
16
ALCOHOL, TOBACCO, CONTROLLED SUBSTANCES
The use and possession of controlled substances or alcohol on the reservation is prohibited. Persons
found in violation of this rule, will be requested to leave the reservation and discharged from the staff.
Possession of controlled substances on the reservation is a violation of Boy Scouts of America policies and
state law. Possession of alcohol on the reservation is a violation of Boy Scouts of America policies, for all
staff members, and state law, for most staff members. Use of them by a staff member could make that
person subject to criminal prosecution.
USE OF TOBACCO: Smoking or chewing tobacco is NOT allowed for any employee under 21 years of
age. Smoking or chewing tobacco by any employee under 21 will result in a notation in an employee's
personnel file and could result in termination. Use of tobacco in program areas is prohibited. (Adult staff
members agree to smoke or chew only in designated areas and not in front of those under 21 years of
age, and not in any buildings. Camp Council rings and their surrounding areas and trails are also
considered to be program areas.)
DISCIPLINE PROCEDURES
In most cases, the discipline procedure of the Theodore Naish Scout Reservation takes place in three stages.
On the first occasion when a staff member commits some act requiring discipline, the staff member is
counseled. The session may include any combination of the following: the Camp Director, the Program
Director, the staff member and the staff member’s area director. The session is a counseling session which
covers how exactly a rule or policy was broken and how to avoid infractions in the future. On a second
infraction, a similar counseling session occurs. If a staff member commits a third infraction of the rules, then
the staff member’s employment is terminated.
If a staff member commits a gross violation of the rules or policies of the camp, or threatens the health of
themselves or others, their employment can be terminated immediately, without following the entire threestep write-up procedure.
YOUTH PROTECTION
Every camp staff member is a state mandated reporter of suspected child abuse, whether or not the abuse
occurs at camp. Under state law, it must be reported in the manner prescribed. Under camp policy, the
report is to be made only to your Camp Director or the Reservation Director. Once the report has been
made the staff person should avoid any further dealing with the situation unless requested to do so by the
Camp Director or Reservation Director. Under no circumstances should you attempt to investigate any
alleged incident.
It is extremely important that you not discuss any suspected or known abuse that you have reported with
any camper, leader, or fellow staff member. The staff member’s protection from being revealed as the
source of the report is negated if the staff person himself discusses the matter with other people.
Abuse can be physical, emotional, sexual, or consist of hazing or harassment. If you have a question as to
whether or not abuse has occurred, you should make the report. Under the law it is not the duty of the
staff member to determine whether or not abuse has occurred or investigate any suspected abuse. Your
only duty is to make a report of known or suspected abuse.
17
HEALTH AND SAFETY
1. Health and Medical Form: All staff members are required to submit a current Annual Health and
Medical Record, signed by a physician (M.D. or D.O.) within a year of the last day of the current
camping season. Parent or legal guardian's signature is also required for staff under age 18.
2. Good Physical Condition: Staff members face a variety of demands throughout the summer. You
need to keep yourself physically fit and alert to be effective as a staff member. Regular exercise is
encouraged and proper diet and rest are required to meet the demands of summer camp.
3. Policy & Procedures Regarding Camp Injuries/ Illness and Applicable Insurance: All injuries or
illnesses should be reported to the Health Lodge Director. Workman’s Compensation Insurance covers
all camp staff injuries that occur on the job (performing assigned duties). All work-related accidents
should be reported to the Reservation Director immediately. He will, with your help, complete a claim
form within 10 days. This is a state law, as much detail as possible should be included on the claim
form. The Council then files the claim forms on your behalf.
All camp staff illnesses or on the job injuries are covered by the Council's accident and sickness
insurance policy with HSR Insurance Company. Please refer to HSR Insurance policy for more details.
Youth and adult camper injuries or illnesses during camp are partially covered by the Council's
accident and sickness insurance policy with HSR Insurance Company. The individual must file these
claims. A copy of every medical report on every accident or illness that requires medical attention will
be sent to the Council Service Center.
Visitors or campers not registered with the Heart of America Council are not covered. They must
provide their own insurance. PLEASE NOTE: Camp staff must avoid saying to any injured person that:
"The Boy Scouts will pay for it." This misleads people, since it is only partially true.
4. Hazardous Material/ Right to Know Policy: The OSHA Hazard Communication Standard and our
Company’s Hazardous Communication Program are designed to inform all of our employees about the
chemical hazards that are present in our facility. As a staff member, you will receive an orientation on
the proper use of all chemicals, including cleaning supplies, disinfectants or other products related to
your job. There will be a review of the Material Safety Data Sheets (MSDS).
Emergency Procedures: Emergency plans will be covered in detail during your camp staff training. In
the event of any type of emergency, each staff member will be expected to follow the orders
immediately. All camp staff members will be assigned emergency duties during staff week and
training sessions will be held. Your full cooperation is necessary. In the event of an emergency, the
understanding of your particular job may control it. Caution campers and instruct them in the
proper methods for building of campfires and cooking fires. You are responsible for safety. Make
sure you handle issues that could cause harm to leaders or scouts when you see them. Radios,
keys, and other emergency equipment will be temporarily issued to certain staff members for use in
drills and emergencies. These are serious events and need to be taken seriously. The equipment used
for them, including but not limited to radios, must be treated properly and maintained in good working
order. Using this equipment in a playful manner or loss can result in immediate termination.
18
CAMP COUNSELOR/DIRECTOR JOB OVERVIEW
REPORTS TO: Program Director
RESPONSIBILITIES
A. Staff Training: Conduct formal and informal staff training as required. Participate in numerous sessions
to insure that program is being carried out as planned. Evaluate instructors regularly, including a
formal mid-summer and season end review; and work with them individually to ensure that they are
making the best possible contribution to the program.
B. Program Promotion: Use every means possible to see that all Scouts and leaders are kept fully
informed of all program features, and be available to discuss the program with leaders in accordance
with printed troop and pack leader guidebooks.
C. Advancement/Merit Badge Enrollment: Balance advancement and merit badge groups to ensure an
equal workload for all instructors. Limit enrollment when required to prevent overcrowded instructional
groups. Be sure that all campers receive the help they need to complete a merit badge. Instructs
program as needed.
D. Patrol Activities: Make program fully available for patrol activities in coordination with the Program
Director. Insure that the workload is evenly balanced among staff.
E. Creativity: This is a quality of all good counselors or directors. It simply means that he or she is
continually looking for ways to improve the program, and to always pass such ideas on to the Program
Director, as appropriate, so they can implement these ideas throughout camp.
F. Supplies & Equipment: The counselor or director is responsible for taking the opening and closing
inventories in his area, and will requisition needed materials from the Program Director and business
manager. Anticipate needs well in advance, and prevent wasteful use of all materials.
G. Records: See that accurate advancement records are kept, and advancement including the merit
badge cards completed for every merit badge offered in their program area. Complete counselor
final report outlines.
H. Counselor: Helping your staff grow through the summer. Insure that the torch is passed on for the
future of Naish Scout Reservation.
I.
Disciplinarian: You are directly responsible for the actions of your staff.
J. Close-out Report: You are responsible for writing and submitting a close out report for your area at
the end of the summer, including recommendations of programs to continue, add, eliminate; potential
staff in the future; and potential supply needs in the future.
K. Perform all other duties as assigned by the Program Director or Camp Director.
19
INSTRUCTOR JOB OVERVIEW
REPORTS TO: Program Area Counselor/Director
RESPONSIBILITIES:
A.
Participate in the local Council Camp School during staff week training.
B.
Develop a thorough knowledge of his particular subject area.
C.
Develop a complete set of notes, visual aids, and reference materials as needed to teach effectively.
D.
Assist Scouts in obtaining the maximum benefit from the program area.
E.
Participate and assist in all patrol activities and camp-wide activities as assigned.
F.
As a staff member, do his part for the character-building process in Scouting and constantly be aware
of the example he is setting for the campers.
G. Perform all duties involving campfires, dining hall programs and tribal activities as assigned.
H.
Follow the camp approved syllabus of instruction.
I.
Be at assigned place on time and prepared to begin activity.
HOW TO MAKE YOUR PROGRAM AREA POPULAR
We all want our program area to be popular with the campers. This can be accomplished by following
these eight simple steps:
 Provide and maintain good facilities and equipment for demonstration and training. Keep things
neat and orderly.
 Know your subject and be able to teach it in an interesting manner.
 Make it fun with games and activities. Games are great for teaching. “Learning by doing” is the
only way you will hold a Scout’s attention.
 Gimmicks – Gimmicks – Gimmicks: Attention grabbing gimmicks to catch and hold the Scout’s
interest. Where? Everywhere is where you should sell your area. Announcements in the dining hall,
posters and signs used in the dining hall, at other areas, at the trading post are all ways of
attracting Scouts to your area.
 Be enthusiastic in your job. Show that you really enjoy your area and its activities. Be involved in
your area.
 Use established camp traditions to enhance your program.
 Use contests, competition, and games to spark interest.
 Take your activities to the Scouts. PROMOTE!! PROMOTE!! PROMOTE!!
 Seek help from other knowledgeable people.
20
THEODORE NAISH SCOUT RESERVATION
EMERGENCY INFORMATION
EMERGENCY CONTACT
 The Central Camp and Cub World Office telephones are for emergencies only.
 The telephone number is 913-422-1035, and is answered 24 hours a day.
SEVERE WEATHER
 When severe or inclement weather is forecast, the Camp Leadership will monitor weather bulletins
on the radio and weather radar screens.
 If a warning is issued, the Camp Leadership will give the order to initiate appropriate safety
measures to campers and staff.
 Campsite Hosts will be sent to campsites.
 Campsite Hosts will move units to campsite storm shelter as directed by the Camp Leadership or if
the storm sirens are sounded.
 Campsite Hosts / leaders will take roll and report to the Camp Leadership.
 Unit Leaders will take their units emergency contact information with them to the shelters.
 The Camp Leadership will monitor storm progress and give the “ALL CLEAR” when appropriate.
FIRE PROTECTION
 In case of fire, notify the Camp Staff immediately.
 Do not attempt to fight any fires yourself.
 Move all campers to safe area, away from fire.
21
HEAT ALERT
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Heat alert will be called by the Camp Leadership.
Reservation Office will announce Heat Alert over the Public Address (P. A.) System.
Increase water consumption.
Decrease or shut down sales of soda.
HEAT ALERT CODES FOR ALL HOAC CAMPS
CODE
HEAT INDEX
ACTION
HEAT ALERT 1
90 – 105 Degrees
Reduce action in sun. Increase
water intake.
HEAT ALERT 2
105 – 130 Degrees
Immediately and sharply
reduce activity. Increase
water intake (1 quart per
hour). Be aware of probable
sun/heat stroke, heat cramps
and heat exhaustion. Seek
shade.
HEAT ALERT 3
130+ Degrees
Take immediate action to
stop activity. Seek cool areas
and increase water intake (2
quarts per hour). Monitor
Scouts for heat/ sun stroke.
Soft drinks or coffee do not replace water. They react differently within the body.
Age increases the probability of heat injury.
INTRUDER
 Camp Leadership will order and announce “lockdown with intruder.”
 Main Gate and Cub World Gates will be closed, locked and monitored by reassigned
Commissioner.
 No one is allowed to enter or leave the reservation without the permission of the Camp Leadership.
 Camp Leadership will call police if necessary.
 Camp Staff will immediately direct all scouts and leaders into nearest secured area. Classes that
are outside of the building SHOULD NOT enter the building. Move outside classes to evacuation
area.
 Secure interior doors.
 DO NOT lock exterior doors.
 Move people away from windows and doors. Turn off lights.
 Move scouts and leaders at camp sites to secure evacuation area.
 Camp Leadership will announce “all clear.”
 After “all clear” staff will account for all scouts and leaders.
INSECT BITES
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Wear light colored clothing to make it easier to spot ticks.
Conduct frequent and thorough "tick checks."
Finding and removing ticks quickly is important.
Wear insect repellents that help repel ticks.
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APPENDIX
The following items must be returned to the Scout Center within two (2) weeks of
receiving your Letter of Employment:
1. Your Letter of Employment/Agreement - must be signed by you and your parent or
guardian if you are under 18 and returned within two weeks. Keep one copy for your
records and return the other one. If you are not able to accept the Letter of Employment as
offered, please return with a brief explanation.
2. W-4 forms - If a paid employee, both Kansas and Federal Forms must be signed and
returned with your Letter of Employment.
3. Automobile Regulations - must be completed and returned with your Letter of
Employment, even if you are not personally driving.
4. Code of Conduct - must be completed and returned with your Letter of Employment.
Bring the following with you when you check-in at the camp staff orientation/parent
meeting:
1. Employment Eligibility Verification (Form I-9) - the supporting original documents
required and I-9 form must be brought with you when you report to camp or the camp staff
orientation. See the back of the I-9 form for a listing of required documents. If you
completed the I-9 in 2013, you will not need to redo for 2014.
2. Current Boy Scouts of America registration card.
3. Adults (all over 18 years of age) need evidence of completion of Basic Leader Training
(Leader Essentials).
To be turned in at the Beginning of Staff Week
1. Annual Health and Medical Record signed by a Physician within the last 12 months.
2. On-line training verification of the following trainings:
i. Youth Protection Training
ii. Hazardous Weather Training
iii. Unlawful Harassment Prevention Training**
**If training was completed in 2013, you will not have to redo for 2014.
23
24
Heart of America Council
Boy Scouts of America
Authorization Agreement for
Automatic Deposits (ACH Credits)
I hereby authorize the Heart of America Council, BSA, hereinafter called COMPANY, to initiate credit entries and to
initiate, if necessary, debit entries and adjustments for any credit entries to my account indicated below and the bank
(depository) named below, hereinafter called DEPOSITORY, to credit and/or debit the same to such account.
Depository (Bank) Name:_________________________________________________________
Check one:
Checking __________________
Savings ____________________
Transit/ABA No.:_______________________________________________________________
Account No.:___________________________________________________________________
This authority is to remain in full force and effect until COMPANY has received written notification from me of its
termination in such time and in such manner as to afford COMPANY and DEPOSITORY a reasonable opportunity to
act on it.
Employee Name:________________________________________________________________
Social Security No.:_________________________________ Date:_______________________
Signed: _______________________________________________________________________
NOTE: Please attach a copy of a voided check for verification with this Agreement. For those using a Savings
Account, please attach a letter from your bank with the required information. A DEPOSIT SLIP IS NOT
ACCEPTABLE FOR EITHER SAVINGS OR CHECKING ACCOUNTS. It is your responsibility to verify with your
bank that your deposit has been posted to your account. It is not the responsibility of the Heart of America Council,
BSA to verify this transaction. Your direct deposit will become effective the next pay period.
Heart of America Council
10210 Holmes Road
Kansas City, MO 64131
VOID
123
Pay to the order of: ____________________________________________________________________
____________________________________________________________________________________Dollars
Bank information
Memo _____________________________
123456789
(Routing Number)
123456789
(Account Number)
25
__________________________________
0000
(Check number)
26
32
CAMP STAFF CODE OF CONDUCT
and Statement of Understanding
Statement of Understanding: All youth and adult staff are selected to represent their local Council
based on their qualifications in character, camping skills, physical and personal fitness, and leadership
qualities. Therefore, all staff members and the parents or guardians (if under 18) are asked to sign the
Code of Conduct and Statement of Understanding as a condition of employment with the further
understanding that serious misconduct or infraction of rules and regulations may result in discharge
from camp staff. Ultimately we want each participant to be responsible for his or her own behavior and
only when necessary will the procedure be invoked to discharge a staff member.
* All youth and adult staff members are expected to abide by the Code of Conduct as follows:
1. The Scout Oath and Law will be my guide while on staff.
2. I will set a good example by keeping myself neatly dressed and presentable. (The official Scout and
staff uniform identifying items are the only acceptable apparel) throughout the entire reservation.
3. I will attend all scheduled programs on time and participate as required.
4. In consideration of other staff members, I agree to follow the bedtime and sleep schedule, unless
otherwise directed by the camp program.
5. I will be responsible for keeping my cabin and personal gear labeled, clean, and neat. I
will do my share to prevent littering of the campgrounds. I will not permit unauthorized
persons to use my cabin or the staff area.
6. I will not have or use cell phones, IPods, or personal computers in program areas.
7. I understand that the purchase, possession or consumption of alcoholic beverages or illegal drugs
by any staff member is prohibited. This standard shall apply to all staff, both youth and adults on
the reservation.
8. Serious and/or repetitive behavior violations by staff including use of tobacco, alcohol, cheating,
pranks, stealing, dishonesty, swearing, fighting, or condoning those actions in others, may result
in immediate discharge from the staff or serious disciplinary action and loss of privileges, or
criminal presentation.
9. I understand that gambling of any form is prohibited and grounds for immediate discharge.
10. I understand that possession or detonation (explosion) of fireworks is prohibited and grounds for
immediate discharge.
11. I will demonstrate respect for camp property and be personally responsible for cleanliness and any
loss, breakage, or vandalism of property. I understand that I am NOT cleared to leave camp at the
conclusion of the summer until my cabin has been inspected for cleanliness and damages.
12. The H.O.A.C., BSA will not be responsible for loss, breakage or theft of personal items. I will
label all my personal items. Theft will be grounds for discharge.
13. I will obey the safety rules and instructions of all supervisors and staff leaders.
14. I understand this CODE OF CONDUCT becomes part of my employment contract.
I have read this Code of Conduct and agree to abide by its contents
Signature of Staff Member
Parent’s Signature, if under age 18
33
34
AUTOMOBILE REGULATIONS
These regulations apply to all persons having a written "letter of employment" as camp
staff members of the Heart of America Council, Boy Scouts of America. It is the policy of
the Council to restrict the operation of motor vehicles to licensed staff personnel 18 years
of age and older. These regulations apply to all motorized vehicles.
1. Staff personnel under 18 years of age may be a passenger in vehicles only when
approved by parents and Camp Director, as stated on parent authorization form.
2. Staff personnel between the ages of 18 and 21 may drive personally owned vehicles
to and from camp, and off the reservation on an authorized leave, when approved by
the Camp Director.
3. Drivers must have Camp Director approval to carry passengers in a personally owned
vehicle. The Camp Director may give approval to carry passengers only for official
camp business or in case of an emergency.
4. No reservation vehicles will be driven either around the camp or beyond the limits of
the reservation unless on official camp business with Camp Director approval.
5. The maximum speed limit for all vehicles on the reservation is 15 mph except where
otherwise posted.
6. All vehicles will be parked only in assigned staff parking areas and will have
Reservation ID prominently displayed.
7. Unauthorized driving, speeding, reckless driving, and any other failure to abide by
these regulations or failure to follow any state regulations, will result in the loss of
driving privileges and may lead to further discipline.
8. Borrowing or loaning of vehicles is prohibited.
9. Staff personnel 16-17 years old may drive their personal vehicles to and from camp
for check-in, check-out, and vacations with parental and Camp Director approval
under extenuating circumstances only. While at camp the vehicles must remain
parked in designated areas and may not be driven on the reservation.
(continued on reverse side)
35
AUTOMOBILE REGULATIONS – 18 AND OVER
CAMP STAFF MEMBER __________________________________________________ AGE __ ___________
Camp _________________
Position ______________________________________________
Current Driver’s License No. ________________________ State ____ Expiration Date _____
Insurance Policy _____________________________ Company ___________________
_______
_____________
Vehicle Color ____________ Vehicle Make __________ Vehicle Model ________ License Plate # ___________
I have read, understand, and promise to abide by the Automobile Regulations. I represent that I currently hold
a valid driver’s license and authorize the Heart of America Council to obtain any of my driving records including
a motor vehicle report.
_
______________________________
___________________________________
Signed
Date
AUTOMOBILE REGULATIONS - UNDER 18
TO BE COMPLETED BY PARENT OR GUARDIAN
Please sign, where indicated, to any or all of the statements, which affect your son or daughter within these
regulations. Your signature will be honored by the Camp Director and your son or daughter will be given
permission to ride or drive only according to the items to which you have given signed permission.
CAMP STAFF MEMBER
_____ AGE__
___
(print name)
Camp
Position
Current Driver's License No.
State
Insurance Policy
Expiration Date
Company
Approval of items 1 – 4 shall authorize the Heart of America Council to obtain a motor vehicle report
and any other driving records pertaining to my son or daughter. I have read and understand the
Automobile Regulations and give permission for my son or daughter to:
1. Be a passenger in an authorized camp vehicle driven by authorized camp personnel.
Signature of approval
Date
(parent or guardian)
2. Be a passenger with another staff member in his/her personal vehicle while on camp property and when authorized by
Camp Director.
Date
3. Be a passenger with another staff member in his/her personal car while on authorized leave from camp.
Date
4. Drive his/her car from home to camp and return.
Date
5. Additional adults my son may ride with:
(include person that may pick
up your staff member on Break Day)
Signature of approval _________________________________ Date
36
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
ATTACHMENT A TO APPENDIX 6
AUTHORIZATION FOR ADMINISTERING OF
MEDICATIONS
Name of Participant______________________________
Unit:________________________________
Over-The-Counter Medications: Ibprofen, Acetaminophen,
INSTRUCTIONS
Antacid, Decongestant, Calamine
1. ALL Participants MUST complete and submit a signed
______________________________________________
copy of this form, even if no medications are
______________________________________________
______________________________________________
provided.
2. Medications (Prescription and Over-the-Counter) must
______________________________________________
be in ORIGINAL labeled container and placed in
(NOTE: Circle what applies, list others that are also
a
zip-lock type bag identified with Scout's name.
provided
3. Any Medications unclaimed at the conclusion of the
Strength, Age/weight appropriate:___________________
event will be destroyed.
______________________________________________
Frequency (As Directed by Manufacturer:_____________
Check
One:
_____No Medications are to be given (including
______________________________________________
Any Special Reason for taking this Medication:_________
over-the-counter).
______________________________________________
_____Authorize Administration of Medication as Indicated
______________________________________________
______________________________________________
______________________________________________
_____________________________________________
______________________________________________
Signed: (Parent or Guardian)
______________________________________________
Date
(NOTE Good for 1 year from signature date.)
Medication:____________________________________
Medication:____________________________________
Strength:______________ Frequency_______________
Reason for taking this
Medication____________________
______________________________________________
Reason for taking this Medication____________________
Approximate Date Started:_________________________
Temporary:_______________Permanent_____________
Side Effects:____________________________________
Side Effects:____________________________________
______________________________________________
______________________________________________
Storage
Instructions:______________________________
Prescribing
Physician:_____________________________
Physician's Phone:_______________________________
Storage Instructions:______________________________
Medication:____________________________________
Medication:____________________________________
Reason for taking this
Medication____________________
______________________________________________
Reason for taking this Medication____________________
Side Effects:____________________________________
Side Effects:____________________________________
______________________________________________
______________________________________________
Storage
Instructions:______________________________
Prescribing
Physician:_____________________________
Storage Instructions:______________________________
Annex M, HRB 2008 EOP
______________________________________________
Prescribing Physician:_____________________________
______________________________________________
Prescribing Physician:_____________________________
M-33
Revised 3-6-08
44
Heart of America Council, BSA
TIME OFF REQUEST
Camp Staff Employee Name
_______________________________________________________________
Camp Department
_______________________________________________________________
Manager
_______________________________________________________________
Date(s) requested: From _______________________To___________________________
Reason for Absence:
__________________________________________________________________________
Employee Signature
Date
Approved ______
Rejected
______
___________________________________________________________________________
Manager Signature
Date
SCOUT OATH
On my honor I will do my best
To do my duty to God and my country
And to obey the Scout Law;
To help other people at all times;
To keep myself physically strong,
Mentally awake, and morally straight.
SCOUT LAW
A Scout is
Trustworthy
Loyal
Helpful
Friendly
Courteous
Kind
Obedient
Cheerful
Thrifty
Brave
Clean
Reverent
46

Dear Staff Member - Heart of America Council

Transcripción

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