Boy Scout Camp Physical Form
| I understand that in my participation in the scouting activities, such involves risk of physical injury or death. I understand that participation in such activities are voluntary with proper instructions to abide to by participants, subject to applicable and standards of conduct. In case of emergency, I understand that all possible efforts shall be made by the medical service provider and/or the scout leader to contact my designated person in case of emergency. In case the designated contact is unreachable, the scout leader in charge shall give permission to the medical provider to to conduct the necessary proper treatment, including hospitalization, anesthesia, or surgery, among others. In case needed, medical providers may disclose the protected health information to the leader in charge, camp medical staff and management as o the findings from observations, test results, and treatment. Further, I give authorization to any volunteer employed by the organization whom knowledge of such information is needed in consideration of the conditions for conducting activities. |
| Yes/No | Details | |
|---|---|---|
| Asthma | No | |
| Diabetes | No | |
| Congenital Heart Disease | No | |
| Chronic obstructive pulmonary disease (COPD) | No | |
| Hypertension | No | |
| Any lung/respiratory disease | No | |
| Ear/eyes/nose/sinus problems | No | |
| Muscular or skeletal condition | No | |
| Had history of a head injury/concussion | No | |
| Altitude or Travel sickness | No | |
| Kidney disease | No | |
| Blood disorders/sickle cell disease | No | |
| Fainting spells and dizziness | No | |
| Psychological or emotional difficulties or Behavioral/neurological disorders | No | |
| Seizures (please indicate last occurrence): | No | |
| Abdominal, stomach, digestive problems | No | |
| Thyroid disease | No | |
| Excessive fatigue | No | |
| Obstructive sleep apnea/sleep disorders | No |
| With Allergies | Details | |
|---|---|---|
| Medicine / Antibiotics | penicillin | |
| Food | crabs | |
| Insects | bees | |
| Animals | ||
| Plants |
| Immunized | Contracted Disease | Details (Including date) | |
|---|---|---|---|
| Chicken Pox | No | Yes | had chicken pox 3 years ago. fully recovered |
| Diphtheria | No | No | |
| Hepatitis A | Yes | No | |
| Hepatitis B | Yes | No | |
| Influenza | Yes | No | |
| Meningitis | Yes | No | |
| Measles/mumps/rubella | Yes | No | |
| Tetanus | No | No | |
| Pertussis | Yes | No | |
| Polio | Yes | No | |
| Other (i.e. HIB) | Yes |
| Status | Details | |
|---|---|---|
| Abdomen | Normal | |
| Eyes | Normal | |
| Ears | Normal | |
| Genitalia/hernia | Normal | |
| Nose | Normal | |
| Throat | Normal | |
| Lungs | Normal | |
| Heart | Normal | |
| Musculoskeletal | Normal | |
| Neurological | Normal | |
| Other |
| With Allergies | Details | |
|---|---|---|
| Medicine / Antibiotics | penicillin | |
| Food | crabs | |
| Insects | bees | |
| Animals | ||
| Plants |
Height/Weight Restrictions
If participant exceeds the maximum weight for the height indicated in the chart below, participant may not be allowed to join a high-adventure activity.
Maximum weight for height:
| Height (inches) | Max. Weight |
| 60 | 166 |
| 61 | 172 |
| 62 | 178 |
| 63 | 183 |
| 64 | 189 |
| Height (inches) | Max. Weight |
| 65 | 195 |
| 66 | 201 |
| 67 | 207 |
| 68 | 214 |
| 69 | 220 |
| Height (inches) | Max. Weight |
| 70 | 226 |
| 71 | 233 |
| 72 | 239 |
| 73 | 246 |
| 74 | 252 |
| Height (inches) | Max. Weight |
| 75 | 260 |
| 76 | 267 |
| 77 | 274 |
| 78 | 281 |
| 79 and over | 295 |
| Meets height/weight requirements | Satisfied |
|---|---|
| No uncontrolled heart disease, asthma, or hypertension | Satisfied |
| Does not have muscoskeletal problems | Satisfied |
| Has not had an orthopedic injury and/or orthopedic surgery in the last six months or possesses a clearance certified by his orthopedic surgeon or treating physician. | Satisfied |
| No uncontrolled psychiatric disorders. | Satisfied |
| Has not had seizures in the last year. | Satisfied |
| Does not have poorly controlled diabetes (if applicable). | Satisfied |
| For scuba diving participants: does not have diabetes, asthma, or seizures; or use of medications to control diabetes, asthma, or seizures is property maintained. |
I certify that I have examined the physical fitness and health history of this person, by which the information indicated above reflects are true and correct:
A Boy Scout Camp Physical Form is a health information form that is compliant to the standards of the Boy Scouts of America. This is a necessary document for any camping activity longer than three consecutive days. This form acts as a multi-purpose form by promoting health awareness. It also serves as an information reference for health officials who may give the person treatment in case of illness or injury during the camping trip. This also serves as the participant's physical preparedness for specialized activities like a jamboree.
This Boy Scout Camp Physical Form PDF template is your quick and comprehensive form for both the applicant and the physician. With the use of the web form, participants or applicants can fill the form and submit it online. No need to fill out paper documents and have better filing management with a database on the cloud. Have a copy of this Jotform based Boy Scout Camp Physical Form PDF Template and start receiving physical fitness forms for your boy scout activities!
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These templates are suggested forms only. If you're using a form as a contract, or to gather personal (or personal health) info, or for some other purpose with legal implications, we recommend that you do your homework to ensure you are complying with applicable laws and that you consult an attorney before relying on any particular form.