Volume 41.1
March 2014
A Spring Start Come spend time with your fellow Arrowmen in the great outdoors at Ingersoll Scout Reservation at the 2014 Spring Conclave. Your cheerful service will make a difference as we prepare Ingersoll for another fantastic season. Spring Conclave is May 16-Â18, with check-Âin on Friday from 5:30-Â7:30 p.m. at the Dining Hall. All Ordeal candidates need to be at the Trailblazer Pa- vilion by 8:00 p.m. A full schedule of the weekend’s events will be available upon arrival. Register and pay your 2014 dues using the registration form in this issue of The Arrow. Save $5.00 by pre-Âregistering before May 2.
What Do You Want In Your Arrow?
Do you want to help make Wenasa Quenhotan Lodge even more fan-Â tastic? The key to success is good communication, so if you have any ideas to improve the Lodge newsletter please email me at: j.lees@wq23.org. I would greatly appreciate any constructive criticism to make The Arrow WKH EHVW LW FDQ EH 5HPHPEHU QR LGHD LV D EDG LGHD QR PDWWHU KRZ LQVLJQLĂ€FDQW or silly it may seem. Joshua Lees Publications 2014
OA Trail Crew Experience If you were out at Winter Banquet you may have seen someone walking around with a sign saying, “Ask me about OA High Adventure.â€? You may ask yourself, “What is OA High Adventure? Why should I care about this opportunity?â€? The answer: What isn’t OA High Adventure? Do you want a unique experience surrounded by other people that love cheerful service just as much as you do in your choice of four different parts of the country or in Canada? The trip is between 8-Â14 days, depending on your program, in the summer at one of the BSA’s High Adventure Bases including The Summit Bechtel Reserve, home of the 2013 National Jamboree. 7KH ZD\ WKH SURJUDP ZRUNV LV WKH Ă€UVW KDOI RI the program is service-Âbased, and the second half is your own adventure. All of this is for a reduced cost, so register now at: adventure.oa-Âbsa.org.
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New Chapter Chiefs Mattameechen Chapter Chance Cook My name is Chance Cook and I’m the 2014 Mattameechen Chapter Chief. I have been involved in Scouting since I was seven and joined Troop 928 when I was 10. Since then, I have earned my Eagle Scout and have gone to Northern Tier and Florida Sea Base. My goals as Chapter Chief are to increase Chapter involvement in events and to get more Arrowmen in my Chapter active. You can reach me through my email, which is Chansu_Itamae@yahoo.com.
Lawasgoteu Chapter Joel Brown Hello! My name is Joel Brown, and I am the 2014 Chapter Chief of the Lawasgoteu Chapter in Wenasa Quenhotan Lodge. My job is to work directly with the troops in the Heart-Â land District. My duties include running monthly chapter meetings, coordinating elections and training, as well as planning chapter activities. Outside of the OA, I work at Ingersoll Scout Reservation as the Eco-ÂCon assistant and made Eagle Scout last November. I look forward to working with the Arrowmen in my chapter both with elections and in fellowship. Contact me at j.brown@wq23.org or jebcards@gmail.com.
Wotamalo Chapter Max Overholt Hi, I’m Max Overholt. I’ll be the 2014 Wotamalo Chapter Chief. This year I will be working on more effectively communicating with troops by talking to troop reps and scout- masters, mass email, meetings, and social media. I hope to improve membership and in- volvement through pamphlets, meetings and getting elections scheduled and completed on time. Too late/last minute elections have been a large problem in years past and will hope- fully be corrected. Scoutmasters and troop reps should contact me as soon as possible to schedule a meeting. Contact me on Facebook, Twitter (@spelcheak), email (m.overholt@wq23.org), or text/phone (1- (309)-Â840-Â4893).
Lowaneu Chapter Co-ÂChief-Â Nate Roberts
Lowaneu Chapter Co-ÂChief-Â Luke Matteson
My name is Nate Roberts. I’m an Eagle Scout and a graduate of Ottawa Township High School. I’m currently going to Illinois Valley Community College and studying criminal justice because I want to be a police RIÀFHU , ZDQW WR GR D ORW IRU WKH 2$ WKLV \HDU DQG , DP very glad to be involved as your Lowaneu Chapter Chief. Contact me for information on elections or with other questions at: tjsner@yahoo.com or n.roberts@wq23.org
Hi my name is Luke Matteson. I am a member of Troop 799 in Marseilles, IL, and Troop 745 in Ottawa, IL. I am a Life Scout currently working towards Eagle. My goals as co-Âchapter chief are to increase attendance of this chapter’s Arrowmen at both Chapter and Lodge events. I also will strive to create a fun environment for the Troop Representatives at a monthly chapter meet- ing at the District Roundtable. If you wish to contact me with a question or to schedule elections, email me at lukematteson97@gmail.com or call/text me at 815-Â992- 8805.
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Letter From the Chief Dear Brothers, 7KH EHJLQQLQJ RI DQRWKHU JUHDW \HDU IRU RXU /RGJH KDV Ă€QDOO\ FRPH 7KLV \HDU WKH LQGLYLGXDOV RQ RXU H[HFX- tive committee are pleased to start our work towards making this year the best that it can be. Whether it is creating a Lodge reunion/ lock-Âin event or making exciting additions to the Spring and Fall Conclaves, we are always work- ing to make Arrowmen more excited to be a part of this Lodge. But the job does not stop there. The job also continues with you. I now challenge you, my Brothers, to continue your journey in our Lodge by reinstating your membership and also bringing those you know who have been with us back again. Bring them to either the Spring or Fall Con- clave and see what great changes we have made. As I leave you, Brothers, remember he who follows such a pathway in unwavering cheerful service will be seen by many others and then, by inspiration, lead them. Yours in brotherhood, Robert Miller Amangi Amemens Machque 2014 Lodge Chief
NOAC 2015 What is NOAC? It stand for National Order of the Arrow Conference, and it happens every two years. The upcoming 2015 NOAC will be like no other in the past because next year is the 100th anniversary of the OA. The six-Âday event (August 3-Â8, 2015) at Michigan State University will be a huge celebration! This is a once-Âin-Âa-Âlifetime event with more than 10,000 Arrowmen from all over the country in attendance. There will be inspirational and unforgettable experiences happening everywhere, along with the fellowship, training of all sorts, adventure, and lots of fun! All who attend NOAC 2015 will also receive a special edition red OA sash–the reverse of our normal sash, with a white arrow on a red background. No extras will be sold–the only way to get one is to be there in person. Learn more about this special sash and other NOAC details at www. noac2015.org.
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Meet the Vice-ÂChiefs Communications Hello reader! My name is James Geraghty, and I am the Vice-ÂChief of Communications for Wenasa Quenho- tan Lodge this year. I am currently a junior at Peoria Notre Dame. I am an avid table tennis player, and I also love golf. If you ever have any questions for me about Order of the Arrow or Scouting in general, feel free to contact me. My email is James.Geraghty@pndhs.org, or you could reach me at (309)303-Â1031. You could also reach my DGYLVRU 6FRWW )LVKHO DW Ă€VKHOV #PWFR FRP , ORRN IRUZDUG WR VHHLQJ DOO \RX $UURZPHQ LQ DQG , KRSH HYHU\RQH has a great year!
Administration The elected Vice-ÂChief of Adminsitration has de-Â FLGHG WR UHVLJQ EHFDXVH RI DQ LQDELOLW\ WR IXOĂ€OO WKH GXWLHV required of him. The new Vice-ÂChief of Administration is J.P. Smith. From Normal, Illinois, he goes to Bloomington Central Catholic High School and belongs to Troop 920. He is very excited to be able to serve on the Lodge Ex-Â ecutive Committee. His goal as Vice-ÂCheif of Administra-Â tion is to help the Lodge achieve its highest potential by leading a great team of people.
James Geraghty (left) and J.P. Smith (middle) WDNH WKH RDWK RI RIĂ€FH IURP &KLHI 5REHUW 0LOOHU
Program The 2014 Vice-ÂChief of Program is Max Broyles. He has been very ac-Â tive with the Order of the Arrow, especially through the Golden Eagles Cer-Â emonies Team. He is a past member of Troop 178 and is currently active in Venture Crew 318. He has also been a staff member at Ingersoll Scout Reser-Â vation. Max is ready to work with Robert Miller, James Geraghty, and J.P. Smith to make 2014 another successful year for the Lodge.
Max  Broyles Page  4
Ask Kitchkinet Kichkinet, , NQRZ WKH 2UGHU RI WKH $UURZ LV QDWLRQZLGH EXW KRZ GR WKH &KDSWHUV DQG WKH /RGJH Ă€W LQWR WKH V\VWHP" -Â-ÂNew Arrowman New Arrowman, 7KH 2UGHU RI WKH $UURZ KDV Ă€YH OHYHOV (DFK OHYHO KDV D FKLHI 7KH VPDOOHVW JURXS LV WKH &KDSWHU :HQDVD Quenhotan has four Chapters: Lowaneu, Wotamalo, Mattameechen (Crossroads District), and Lawasgoteu (Heart- land District). The chiefs for each Chapter are Nate Roberts and Luke Matteson ( Co-Âchiefs), Max Overholt, Chance Cook, and Joel Brown respectively. The Chapter is the base unit for the OA. The Lodge is the next unit. The Lodge has at least three events every year: Fall Conclave in September, Spring Conclave in May, and Winter Banquet in January. The current Lodge Chief is Bob Miller. Information about the Lodge and the Chapters can be found on the Wenasa Quenhotan website: wq23.org. The Lodge is part of a Section. Our Lodge is in Section C-Â3A. The main event of the section is Section Con- clave, which is hosted by a different Lodge in our section each year. This year Section Conclave is at Camp Loud Thunder in Illinois City, IL, which is about an hour from Ingersoll Scout Reservation. The Section is in the Central Region. Then the highest level is the National Order of the Arrow. The major national event is NOAC or the National Order of the Arrow Council. The next NOAC will be the biggest ever to cel- ebrate 100 years of the Order of the Arrow. If you are interested in any of these upcoming events feel free to contact our Lodge Chief Bob Miller at b.miller@wq23.org or check online at wq23.org
Kichkinet
2013 Vigil Class
Vigil Honor Nominations Vigil is the highest honor that can be given to a member of the Order of the Arrow. It is only bestowed upon those few people who truly go above and beyond what is expected of them, not only in their Troop and Lodge, but also in their homes and communities. These people resemble the true Spirit of Scouting, so we recognize them for WKHLU XQVHOĂ€VK VHUYLFH WR RWKHUV For a member of the Order to be nominated for the Vigil Honor, the person must have been a Brotherhood member for at least two years and have his or her dues paid for the present year. If these requirements have been IXOĂ€OOHG WKHQ WKH SHUVRQ FDQ EH QRPLQDWHG IRU 9LJLO HLWKHU E\ D ZULWWHQ QRPLQDWLRQ IRUP RU YHUEDOO\ GXULQJ WKH 9LJLO nominations at Spring Conclave on Friday night. Once the nominations are complete, the Vigil Selection Committee will select who will receive the Honor. The chosen members will be called out after the call-Âout ceremony at summer camp. ,I \RX NQRZ D PHPEHU RI RXU /RGJH ZKR \RX IHHO LV GHVHUYLQJ RI WKH 9LJLO +RQRU SOHDVH Ă€OO RXW D QRPLQDWLRQ for him/her and submit it at Spring Conclave.
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Winter Banquet 2014 The rescheduled 2014 Winter Banquet came off without a hitch, having been postponed from the frigid win- tery blast that hit Central Illinois on January 5. A meal of baked ham, cheesy baked potatoes, and the ‘must have’, ever-favorite sweet potato casserole was generously served up with lots of fellowship. There were 136 Lodge mem- bers, Section leadership, and family guests in attendance at the event at the Eureka United Methodist Church. Earlier, a Youth Subsidy Auction sold a record $592 (from records kept over the past decade) to spirited bidders. All 114 lots sold, with the bulk being donated from long-time Scouter John Ewan’s estate, a collection of patches and neckerchiefs where he served on staff, many dating back to the Creve Coeur Council days. The program after the meal included the installment of Lodge Chief Bob Miller and his Vice-Chiefs and a message from keynote speaker Bill Sellers. Bill captured everyone’s attention when he passed out $100 in one dollar bills, with a question of what can you do with your dollar?** At the end of the evening he suggested to the audience to give back their dollar and then some to the Youth Subsidy Fund, with ap- proximately $190 being turned in. The 2013 Elangomats were named: Hayden Gol- emon, Christopher Knoll, J.P. Smith, Alexander Wilson, Joel Brown II, Matthew Nagle, Brian Raupp, Nicholas Thompson, Bennett Taylor, Nate Roberts, Ian Campbell, Jordan Ford, Tyler Mezel, Matthew Benedict, and Matthew Parac. An ex- tended Elangomat Award (for 50% conversion of their Clans to Brotherhood) was presented to Lucas Elmore, Bennett Taylor, Benjamin Mueller, Nicholas Raupp (twice), and Chase Ramseyer. The evening was capped off with the recipients of the Founders Award being announced: Justin Lane and Craig Wallace. The recipient of the Lodge Service Award is Stephen Hamm. ** - Please check with Bill Sellers for the essence of his message!
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Broken Arrows It is with reverence that we take a moment to remember our Brothers that have passed away recently. 7KH\ ZHUH UROH PRGHOV UHVSHFWHG DQG ÀQH H[DPSOHV RI WKH %6$
Anthony M. Condie
Ordeal 1974
Peru, Troop 12
Gary D. Caldwell
Ordeal 1983
Bloomington, troop unknown
Charles I. Walker
honor unknown
Ottawa, troop unknown
Roger E. Dotson
Brotherhood 1972
Le Roy, Troop 50
David E. Lakin
Vigil 1994
Wotamalo DML
Willard “Skip� Colvin
Brotherhood 1957
Farmington, Troop 79
James “Art� Walters
Ordeal 1977
Tiskilwa, Troop 91
,YDQ & 'XIĂ€HOG
Brotherhood 1973
Glasford, Troop 56
Richard L McCoy
Ordeal 1979
Streator, Troop 75
Charles A. Mathiesen
Ordeal 1977
Dwight, Troop 77
William R. DuBois
Brotherhood 1997
Rome, Troop 53
Vern E. Sipes
Vigil 1982
Canton, Troop 104
Their cheerfulness and their service will be deeply missed.
Welcome to New Lodge Members! These Arrowmen have recently transferred their membership to Wenasa Quenhotan Lodge 23. Give them a hearty welcome when you see them! Stanley Sotomayor, youth with T627 in East Peoria, transferred from Illini Lodge 55. Glen Harbin, adult with P3953 in Bloomington, transferred from Glikhikan Lodge 106.
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Table of Contents Spring Conclave
Mission of the Wenasa Quenhotan Lodge 1
What Do You Want In Your Arrow? 1 OA Trail Crew Experience
1
New Chapter Chiefs
2
Letter from the Chief
3
NOAC 2015
3
The New Vice-Chiefs
4
Ask Kitchkinet
5
Vigil Honor Recommendations
5
Winter Banquet
6
Broken Arrows
7
New Lodge Members
7
If you would like to start receiving The Arrow via email, please email s.cantrell@wq23.org and say that you would like to go green. Save the Lodge money, receive faster/in color, and enjoy it anywhere!
Visit us at www.wq23.org!
It is the mission of this Lodge to promote Scout camping, to assist in year-round camp maintenance and improvement, to provide an opportunity for young men to develop leadership abilities, and for each member to set an example of the high ideals of Scouting and the Order to each of our units. The Arrow is published four times a year and a great way to get news out to all active members in our lodge. If you would like to submit anything or have any questions;; please contact any of the following: James Geraghty 2014 Vice-Chief of Communications (309)303-1031 j.geraghty@wq23.org
Robert Miller 2014 Lodge Chief (309)453-6378 b.miller@wq23.org
Scott Fishel 2013-2014 Joshua Lees Publications Adviser Publications (309)256-8895 (309)258-9033 V ¿VKHO#ZT RUJ j.lees@wq23.org
ORDEAL CANDIDATE INFORMATION Wenasa Quenhotan Lodge #23 invites all Scouts who were called out as candidates for the Order of the Arrow to enter into our brotherhood by completing their Ordeal at the 2014 Spring Conclave on May 16-18, at Ingersoll Scout Reservation. The fee for the Ordeal is $35.00. This price covers meals, an event patch, a Lodge flap, a sash, a handbook, and dues for the 2014 dues year. Candidates are urged to pre-register and pay in advance to be sure there will be enough items for all new members to get through check in. Please use the enclosed registration coupon. Check-in is open from 5:30-7:30 PM Friday for Ordeal candidates in the Dining Hall. All candidates must at the Trailblazer Pavilion at Ingersoll Scout Reservation (located at the bottom of the Dining Hall hill) by 8:00 PM for the Pre-Ordeal Ceremony. Ordeal candidates must be in attendance the entire weekend to become a member of the Order of the Arrow. Departure time from the Conclave will be approximately 10:00 a.m. on Sunday.
IMPORTANT: All Ordeal candidates will need to bring the following items for the weekend: • Old work clothes (should be worn on arrival) • Sleeping bag • Ground cloth (large) • Poncho or Rain Suit • Work gloves Bring the following for later in the weekend: • Class “A” uniform and extra clothes • Toiletries (towel, soap, etc.) • Tent for Saturday night We suggest you arrive wearing your work clothes, and that you have a separate package for toiletries, uniform, etc. You will need a tent for sleeping on Saturday night unless you already have sleeping arrangements provided. Please make sure you fill out the medical information portion of the registration coupon. The Lodge looks forward to welcoming many new members this spring.
BROTHERHOOD INFORMATION If you took your Ordeal at the 2013 Spring Conclave, or before, we strongly encourage you to seal your membership in the Order by becoming a Brotherhood Member. To become a Brotherhood member, you must fulfill the following requirements: •
Ten months service as an Ordeal member.
•
Registered active membership in Scouting.
•
Registered active membership in the OA
•
Memorize the Obligation, the Song of our Order, and the Admonition. It is important that you not only meet the these requirements, but that you are prepared for the Brotherhood. You must write a letter to the Lodge Secretary expressing your feelings. Include the following in your letter:
•
Explain what you think the Obligation means.
•
Describe how you have been fulfilling this Obligation of cheerful service in your troop and in your daily life, and how you have personally used your understanding of the traditions of the Ordeal to aid in this service.
•
Describe the specific plans you have for rendering service to the Lodge in fulfillment of the new pledge you expect to take.
At the completion of the Brotherhood ceremony, you will receive your Brotherhood sash and later that evening, you will receive your red-bordered flap (awarded only to Brotherhood and Vigil members) and a Brotherhood certificate to commemorate the occasion. Please remember to indicate your Brotherhood candidacy on the Conclave registration form. You may include your Brotherhood letter with the registration, or bring it with you to the Conclave.
Spring Conclave Registration/ Dues Payment May 16-18, 2014 Ingersoll Scout Reservation
Full Name
City / Town BSA ID #
(
Zip code E-mail
)
Chapter (District)
Unit
C heck one of the follow ing:
If you are coming to the Spring Conclave as a General Member, your event fees are $15 for registration by May 2. If you are coming to the Spring Conclave as a General Member, your event fees are $20 for registration after May 2. If you are doing your Ordeal at the Spring Conclave, your total event fees are $35 If you are doing your Brotherhood at the Spring Conclave, your total event fees are $32 If you are an Elangomat at the Spring Conclave, your event fees are waived.
!"#$%#&$''$()&$&(*+,&*-&,*./&)#$"')&-*/0%&1234&5#$')&-*/0%&4&6&27&-*/&')#&"*89#&'*&/#'$:;&-*/&-.'./#&#<#;'%&:;&=>?@& & The Lodge's Yearly Dues are $13 per person. (Ordeal Fees include one year of dues.) Total Fees/Dues/ Donations $
Donation to the Lodge Building Fund $
I wish to receive the OA Newsletter (The Arrow) electronically (Y/N) _____ My Mailing Label information OR Email Address has changed (Y/N) _____ Please mail registration, payment, and medical forms to Wenasa Quenhotan Lodge, 614 N.E. Madison Ave. Peoria, IL
61603 If your address, email or any other membership information has recently changed, please check the box above indicating a need for a change. Be sure to include all mailing and email information as outlined above. Lodge Policy states that a member must have paid dues for the current calendar year to be considered active in the Lodge and receive Lodge mailings and emails. Anyone who has lapsed in dues payment must pay the entire year's dues to be reinstated in the Lodge. Dues are not prorated. To receive The Arrow electronically in the future, please make sure you include above the BSA# and your Email ID.
Alertness to the needs of others is the mark of the Vigil Honor. It calls for an individual with an unusual awareness of the possibilities within each situation. The Vigil Honor is the highest honor that the Order of the Arrow can bestow upon its members for service to lodge, council, and Scouting. Membership cannot be won by a person's conscious endeavors. The Vigil Honor is a high mark of distinction and recognition reserved for those Arrowmen who, by reason of exceptional service, personal effort, and unselfish interest, have made distinguished contributions beyond the immediate responsibilities of their position of office to one or more of the following: • Lodge • Order of the Arrow • Scouting community • Scout Camp Under NO circumstances should tenure in Scouting or the Order of the Arrow be considered as reason enough for a Vigil Honor recommendation. Any member of the Order of the Arrow registered in Scouting and in good standing in a regularly chartered lodge is eligible for recommendation to the National Order of the Arrow Committee for elevation to the Vigil Honor provided that, at the time of the recommendation, the individual has been a Brotherhood member for a minimum of two years. A lodge may nominate a maximum of two percent of their registered Arrowmen once a year, through the Vigil Honor petition, found in the annual re-charter packet. At least 50 percent of all nominated must be under 21 at the time of nomination. Please Consider ___________________________________________________________for the Vigil Honor Date:______________________________ Home Address:_____________________________________________________________________________ City/Town:________________________________________Zip Code:_________________________________ Birth Date:________________ Ordeal Date:_____________________ Brotherhood Date:__________________ (NOTE: Any Brother recommended for the Vigil Honor must be a Brotherhood Member for a minimum of TWO YEARS, as of the selection date, to be eligible for the Vigil Honor.) Unit#_________________ Position in Unit:__________________________________________ Suggestion for Vigil Name:______________________________________________________________________ Please State Specific Reasons for Selection:_________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ ___________________________________________________________(if more room is needed continue on back) Please select a maximum of three of the following words which best describe the person whom this recommendation form is for: Ambitious Attentive Brilliant Charismatic Cheerful Compassionate Creative Dependable Diligent Easy-going Faithful Friendly Helpful Honest Humble Lively Observant Peaceful Persevering Reliable Skillful Thoughtful Wise Your Name:________________________________ Phone Number: (________)__________________________ Address:________________________________________________________________________________ City/Town:________________________________________ Zip Code:____________________________ Please Mail To: OA Recognition Chairman c/o W.D. Boyce Council 614 N.E. Madison Ave. Peoria, IL 61703
Full name: _________________________________ DOB: ______________ Allergies: __________________ Emergency contact No.: ___________________
Annual BSA Health and Medical Record Part A
GENERAL INFORMATION
High-adventure base participants: Expedition/crew No.: __________________________________________________ or staff position: _______________________________________________________
Name ___________________________________________________________________ Date of birth ________________________________ Age _____________ Male
Female
Address _________________________________________________________________________________________________________________________ Grade completed (youth only) __________ City _____________________________________________________________________ State ____________ Zip ____________________________ Phone No. ________________________________ Unit leader ______________________________________________________ Council name/No. ___________________________________________ Unit No. ___________________ Social Security No. (optional; may be required by medical facilities for treatment) _______________________ Religious preference ______________________________ Health/accident insurance company __________________________________________________________ Policy No. ________________________________________________________
ATTACH A PHOTOCOPY OF BOTH SIDES OF INSURANCE CARD. IF FAMILY HAS NO MEDICAL INSURANCE, STATE “NONE.” In case of emergency, notify: Name _________________________________________________________________________________ Relationship _____________________________________________________________ Address _________________________________________________________________________________________________________________________________________________________________ Home phone _________________________________________ Business phone _______________________________ Cell phone ___________________________________________ Alternate contact _________________________________________________________________________ Alternate’s phone ___________________________________________________
HEALTH HISTORY Allergies or Reaction to:
Are you now, or have you ever been treated for any of the following: Yes
No
Condition
Explain
Asthma Last attack: ____________ Diabetes Last HbA1c: ____________ Hypertension (high blood pressure) Heart disease (e.g., CHF, CAD, MI) Stroke/TIA Lung/respiratory disease Ear/sinus problems Muscular/skeletal condition Menstrual problems (women only) Psychiatric/psychological and emotional difficulties Behavioral disorders (e.g., ADD, ADHD, Asperger syndrome, autism) Bleeding disorders Fainting spells Thyroid disease Kidney disease Sickle cell disease Seizures Last seizure:____________ Sleep disorders (e.g., sleep apnea) Abdominal/digestive problems Surgery Serious injury Other
Medication ____________________________________ Food, Plants, or Insect Bites _________________ _________________________________________________ Immunizations: The following are recommended by the BSA. Tetanus immunization is required and must have been received within the last 10 years. If had disease, put “D” and the year. If immunized, check the box and the year received. Yes
Use CPAP: Yes
No
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.
No
Date Tetanus ________________________ Pertussis _______________________ Diphtheria ______________________ Measles ________________________ Mumps _________________________ Rubella _________________________ Polio ____________________________ Chicken pox____________________ Hepatitis A _____________________ Hepatitis B _____________________ Influenza _______________________ Other (i.e., HIB) ________________
Exemption to immunizations claimed (form required). (For more information about immunizations, as well as the immunization exemption form, see Scouting Safely on Scouting.org.)
Medication _____________________________ Strength ________ Frequency ____________ Approximate date started ________________ Reason for medication ___________________ ________________________________________
Medication _____________________________ Strength ________ Frequency ____________ Approximate date started ________________ Reason for medication ___________________ ________________________________________
Medication _____________________________ Strength ________ Frequency ____________ Approximate date started ________________ Reason for medication ___________________ ________________________________________
Medication _____________________________ Strength ________ Frequency ____________
Medication _____________________________ Strength ________ Frequency ____________
Medication _____________________________ Strength ________ Frequency ____________
Approximate date started ________________ Reason for medication ___________________ ________________________________________
Approximate date started ________________ Reason for medication ___________________ ________________________________________
Approximate date started ________________ Reason for medication ___________________ ________________________________________
Administration of the above medications is approved by (if required by your state): ________________________ / _______________________ Parent/guardian signature
and/or
MD/DO, NP, or PA signature
Be sure to bring medications in sufficient quantities and the original containers. Make sure that they are NOT expired, including inhalers and EpiPens. You SHOULD NOT STOP taking any maintenance medication. 680-001 2011 Printing Rev. 2/2011
High-adventure base participants:
Part B
Expedition/crew No.: __________________________________________________ or staff position: _______________________________________________________
INFORMED CONSENT AND HOLD HARMLESS/RELEASE AGREEMENT 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.
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. 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. Without restrictions. With special considerations or restrictions (list) ____________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________________ TALENT RELEASE AGREEMENT 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. 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. Yes
No
ADULTS AUTHORIZED TO TAKE YOUTH TO AND FROM EVENTS: You must designate at least one adult. Please include a telephone number. 1. Name _________________________________________________________________ Telephone ______________________________________ 2. Name _________________________________________________________________ Telephone ______________________________________ 3. Name _________________________________________________________________ Telephone ______________________________________ Adults NOT authorized to take youth to and from events: 1. Name __________________________________________________________________________________________________________________ 2. Name __________________________________________________________________________________________________________________ 3. Name __________________________________________________________________________________________________________________ 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. If I am participating at Philmont, Philmont Training Center, Northern Tier, or Florida Sea Base: 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 health-care provider. Participant’s name _______________________________________________________________________________________________________ Participant’s signature __________________________________________________________________ Date ____________________________ Parent/guardian’s signature ______________________________________________________________ Date ____________________________ (if participant is under the age of 18)
Second parent/guardian signature ________________________________________________________ Date ____________________________ (if required; for example, CA)
This Annual Health and Medical Record is valid for 12 calendar months.
Part B
Full name: ___________________________________________________________ DOB: __________________
680-001 2011 Printing Rev. 2/2011