Annual Health and Medical Record

Before participating in any outdoor or overnight event, each youth member, parent or adult leader needs to submit a completed medical record. You have two options:

• Medical Form Parts A and B - This is the minimum medical record for a weekend trip, requires no doctor signature and must have been submitted to the Troop within the previous year.
• Medical Form Parts A, B and C - This is required for Summer Camp (or any other trip exceeding 72 hours), does require a doctor signature, and the doctor exam must have taken place within one year of our week at camp.

If you have the vaccination/exam printout from the participant's last exam and that is after last July, your simplest option is to complete the A, B and C form now, so you don't have to do a second form later.

Pro tip: Save the form to your own drive before you start completing it electronically; otherwise, your entries will be lost when you do save it.

Signatures: These forms require wet signatures, i.e., you use a pen. Do not sign them electronically.

Here are responses for a few of the fields on Part B Page 1:

• If you are in Troop 54:
  • Unit leader: Joshua Froimson
  • Mobile phone (for unit leader): 774-641-1560
  • Council Name/No.: Heart of New England / 230
  • Unit No.: Troop 54
• If you are in Troop 7054:
  • Unit leader: Khoa Kennedy
  • Mobile phone (for unit leader): 508-498-3502
  • Council Name/No.: Heart of New England / 230
  • Unit No.: Troop 7054
• If you are in Pack 54:
  • Unit leader: Joshua Froimson
  • Mobile phone (for unit leader): 774-641-1560
  • Council Name/No.: Heart of New England / 230
  • Unit No.: Pack 54

Please review your medical record for the following frequently missed items (you will need to print this page if you want to actually check it off):

• A copy of both sides of the participant's medical insurance card is attached.
• On the Part A form under "List participant restrictions, if any", either "None" is checked or restrictions are entered. The check box sometimes prints empty even when you have it checked electronically.
• On Part A, if the participant is a youth member, the parent/guardian has signed and dated at "Parent/guardian signature for youth".
• On Part A, the participant has signed and dated at "Participant's signature".
• On Part B1, you have entered the name of the insurance company and the policy number in the two spaces provided,
• On Part B2, Yes or No is checked before "Non-prescription medication administration is authorized with these exceptions" is checked.
• On Part B2, on that same line, any exceptions are listed, or the word "none" is entered.
• On Part B2, below that line, if the participant is a youth, the parent/guardian has signed the space provided.
• On Part B2, if no medications are routinely taken, the box for this is checked.
• A complete immunization record is attached.
• On Part C, the health care provider has signed and dated at Examiner's Signature and Date.

Note: A "medication" is something that has an active pharmaceutical ingredient. For example, sun screen is not a medication.

Page updated 9/13/20 J. Froimson