Documented medical conditions that prevent safe administration of immunizations can be documented on the Annual Health and Medical Record.

You may also request an exemption using this request: Immunization Exemption Request.

The Immunization Exemption request will typically not impact the individual’s ability to participate in Den and Pack activities.  However, the individual requesting an exemption may be prohibited from participating in some Council or other activities considered higher risk.

We work hard to keep our Scouts and other program participants safe during our events, but sometimes injuries happen. Scouts are required to complete an Annual Health & Medical Form every year so that our Leaders have the information and authorization they need to address any health issues that may arise.

Download a Copy of the Health Form

Download a copy of the BSA Health Form using the button below.  This form is the official Annual Health and Medical Record of the Boy Scouts of America. It is not valid if modified or altered. This includes deleting or crossing out sections.

Download BSA Health Form

There are three parts to the BSA Health Form:

• Part A: Informed Consent, Release Agreement, and Authorization
• Part B: General Information/Health History
• Part C: Pre-Participation Physical

Parts A & B are required to participate in any Scouting event and can be completed by a parent or guardian.  Part C is required for any resident campers or for events of 72 hours or more.  Part C must be completed by a certified and licensed physician (MD, DO), nurse practitioner, or physician assistant.

Completing Part A (Page 1)

Part A of the BSA Health Form is focused on providing the Troop and the BSA with consent for the individual to participate in Scouting activities, releases the BSA from claims that could result from participating in Scouting activities, and authorizes the Troop and the BSA to deliver all or some of the Scouting program to the individual.

• Page Header
  • Enter the individual’s Full Name and Date of Birth in the specified fields.
  • The High-adventure base participants section does not need to be completed.
  • Duplicate this information on all subsequent pages (If you are completing this form electronically, this information will be populated on all subsequent pages.)
• Informed Consent, Release Agreement, and Authorization
  • Read the content of this section.
  • If you do not want your Scout to use a BB device, check the box next to Checking this box indicates you DO NOT want your child to use a BB device.
  • If you wish to restrict the activities the individual can participate in, list them in the section titled List participant restrictions, if any.
  • If the individual has no restrictions, check the box marked None.
  • You will complete the Participant and Parent / Guardian Signatures in a future step.
• Adults Authorized / Not Authorized to take youth to and from events.
  • This section identifies the adults who are or are not permitted to take Scouts to or from events. Include yourself as an authorized Adult.  The Pack will only let authorized adults pickup a Scout after an event.  For Council events (i.e. Day Camp), the individual picking the Scouts up from the event must be listed in this section.

Complete Part B (Pages 2 & 3)

Part B1 (page 2) of the BSA Health Form gathers general information about the individual and a health history. Part B2 (page 3) continues gathering information about the individual’s health history including information about allergies, medications, and immunizations.

• General Information
  • Populate the fields listed in the document.  Enter the following information for the  Unit Leader and Council / unit information:
    • Unit Leader: Tim Maloney
    • Unit Leader Mobile #:  (Check TroopTrack for this information)
    • Council Name/No: Moraine Trails Council (500)
    • Unit No: Troop 457
  • Include the name of the individual’s Health/Accident Insurance Company and Policy Number as well as a photocopy/scan of both sides of the individual’s insurance card.  (Some insurance providers allow you to download a PDF copy of your insurance card which can be included with your Health Form submission.)
  • For the emergency contact, we encourage you list an individual who is less likely to be attending events with the individual.
• Health History
  • Check the Yes or No box next to each condition to indicate whether the individual has (Yes) or does not have (No) the condition.
  • If you check Yes, explain the condition in the space provided.  Note that some conditions have additional questions that should be answered if they apply.
  • If you need additional space to explain a condition or to answer the last two questions (list surgeries / hospitalizations and other medical conditions not listed), attach additional pages to the completed health form.
• Allergies / Medications: Complete the fields in this section.  Be sure to do the following:
  • If the questions doesn’t apply to the individual, be sure to check NO to the question.
  • If the individual has allergies, provide additional specifics in the provided space or attach additional pages to provide details.
  • If the individual does NOT routinely take medication, you should check the Check here if no medications are routinely taken option.
  • Attach additional pages if you need more space to list medications but be sure to check the If additional space is needed, please list on a separate sheet and attach option.
  • The Yes/No option below the medication listing is authorization for BSA Leaders to administer non-prescription medication to the individual.
    • Marking NO prohibits BSA Leaders from administering non-prescription medication.
    • Marking YES allows BSA Leaders to administer non-prescription medication.
    • You can limit the non-prescription medication that can be administered by listing them in the space marked Non-prescription medication administration is authorized with these exceptions.
  • For Youth Only: If you list any prescription medications or authorize non-prescription medication, a parent must sign in the location marked Administration of the above medications is approved for youth by.
• Immunization:
  • The BSA requires that participants have a tetanus immunization received within the last 10 years.  All other immunizations are recommended by not required.  (See also How do I request an immunization exemption?)
  • Check off whether the individual has (YES) or has not (NO) received the immunization.
  • If the individual has had the disease (regardless of vaccination status), list the date of the infection.
  • List the dates of the individual received the immunization in the space provided.
  • Exemption to immunization:If the individual is would like to be considered exempt from the immunization requirements, check YES and see How do I request an immunization exemption? for additional instructions.
  • NOTE:  You may attach a copy of the individual’s immunization record to support this section, however you must populate the Yes / No and Had Disease items in this section.
• Additional Medical History
  • There is a small box on the right side of the form where you can capture any additional information about the individual’s medical history.
  • Add any additional information that may be relevant to how the individual participates in the Scouting program.
  • Attach additional documentation as necessary.

Complete Part C

Part C of the health form requires a medical professional to complete a physical for the individual. The BSA requires that the form be completed by certified and licensed physicians (MD, DO), nurse practitioners, or physician assistants.

Print, Sign, and Submit

If you completed the form electronically, print it out so if can be signed.

• For Youth:
  • Have the Youth sign and date the document on Page 1 under the Participant’s Signature.
  • Have a parent or guardian sign and date the document on Page 1 under the Parent/guardian Signature for youth.
  • Have the Youth sign and date the document on Page 1 under the Participant’s Signature.
  • If any prescription medications were listed or administration of non-prescription medication were authorized, the parent/guardian should also sign the location marked Administration of the above medications is approved for youth by on page 3.
• For Adults: Sign and date the document on Page 1 under the Participant’s Signature.

You can submit the completed and signed forms and any additional supporting documentation as a scanned or a hard copy to any adult Troop Leader.

Submission Checklist

When you submit the form, make sure the following is true:

• All information is complete and accurate to the bet of your knowledge
• You included all three/four pages of the Health Form.
• All required fields are populated.
• The appropriate signatures are on page 1 and (if necessary) page 3.
• You included a copy of both sides if the individual’s insurance card.
• You include any relevant supporting documentation (i.e. immunization record, immunization exemption request, additional medications, additional explanations for the medical history)