• New forms required every September for all scouts, leaders and participating adults.
• Completed by parent/guardian or adult participant.

• Required for events exceeding 72 hours or for strenuous and demanding activities.
• Completed, signed and dated by licensed health care provider.
• Valid for 12 months from date signed.

• Required for BSA high adventure programs.

• Provide all requested information (except SSN). Remember to copy both sides of your insurance card.
• Unit/Troop information
  • Unit Leader - Dave Clark
  • Council Name/No. - Bucks County/777
  • Unit No. - Troop 29
• Immunization list from health care provider may be attached for immunization dates.

• It's helpful, but not required, to authorize more than a few drivers.  If the number of drivers is limited, the scout's parents/guardians will be responsible for ensuring that one of their authorized drivers agrees to drive the scout to and from the event.
• As required for Ockanickon, please have your son provide his signature in Part B. It also helps teach personal responsibility.

Part C

• Double check to be sure this form is fully completed.
• A certified and licensed doctor (MD or DO), physician assistant, or nurse practitioner must sign (stamp accepted) and DATE the form in the space provided.
• Be sure the health care provider's address is filled in.