2024 LEADER'S GUIDE CAMP TIFIE SCOUTS BSA
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CAMP TIFIE
SCOUTS BSA 2024
LEADER’S GUIDE
2024 Leader’s Guide
CAMP TIFIE
CONTACT INFORMATION
Website: utahscouts.org/tifie
CAMP RESERVATIONS AND INFORMATION
TERRI COMBER
Camping Assistant
terri.comber@scouting.org
(801) 479-5460
CAMP FEE PAYMENT INFORMATION
For mailing payments use the following address:
Crossroads of the West Council
1200 E 5400 S
Ogden, Utah 84403
For online payments visit:
utahscouts.org
TIFIE CAMP DIRECTOR
Dan Webb
directordanwebb@gmail.com
CAMP TIFIE
EMERGENCY PHONE DURING CAMP SEASON
(435) 770-9684
Camp Tifie does not discriminate against anyone on the basis
of race, color, national origin, religion, age, sex, handicap, or
any other delineation of peoples.
TIFIE
CAMP OVERVIEW
Nestled high in the Wasatch Plateau overlooking Utah’s beautiful
Sanpete Valley, Camp Tifie is 600 acres at 7,500 feet above the Mt
Pleasant, along Sky Haven Drive. The facility provides premium
outdoor experiences for all age groups! The camp also has a full-
service dining hall.
Tifie is nationally accredited by the Boy Scouts of America.
2 250 30
Weeks to choose Total camp Campsites to
from during 2024. capacity each choose from.
session.
2 Hours from Salt Lake City
600 Acres above Mount Pleasant, Utah
Typical summer daytime high temperatures with
High 80’s nighttime lows in the 50’s.
TIFIE IS…
ADVENTURE: We delight in the thrill of discovery and helping others discover their own adventures.
ENTHUSIASTIC: We love Tifie and we joyfully do our best to make each session the most exciting camp
experience ever.
DIVERSE: We value all people and celebrate the differences that make us all special.
FRIENDLY: We reflect the values of the Scout Oath and Law in all that we do.
SERVICE DRIVEN: We are happy to be here and honored to serve you.
PLANNING FOR CAMP
We are very happy you have chosen Camp Tifie for your upcoming Scout camp! We promise to do all
in our power to make your Scout camp memorable and successful. We have found the best Scout
camps are those planned together by youth and leaders. One way to structure your leadership is
outlined below.
Scoutmaster
As the adult in charge of your event, it is your responsibility to oversee the entire organization and
development of the event and to see the goals of the event are met. We encourage you to keep a low
profile. Let the youth plan their own agenda as much as possible. There will be times when your
expertise and experience will be needed, so don't hesitate to offer suggestions and ideas to smooth
out the rough spots. Youth want to show that they are capable and will do an excellent job when
given the opportunity.
Senior Patrol Leader & Patrol Leaders
As youth leaders, you have one of the most important jobs. Scout camp may have more influence on
your peers than any other activity held during the year. You are responsible for overseeing the
planning and conducting of the events while at Camp Tifie. Remember to keep the goals for the
events in mind when planning. Be prepared for committee meetings and set specific tasks to reach
your goals.
Prior to camp
• Work with adult leaders
• Develop goals and themes
• Coordinate all committees
• Follow deadlines
During the camp
• Work with Camp Tifie Staff
• Conduct all meetings
• Orientation & general meetings
• Special meetings (firesides, testimonies, etc.)
• Encourage peers to follow camp rules
• Keep records of advancement & participation (Fellowship of the Bison, etc)
Adult Supervisors:
We strongly urge you to plan sufficient adult supervision for the size of your Scout camp group.
Schedules:
Please consult the week at a glance schedule. Camp Tifie offers activities throughout the day, including
evening programs, merit badge activities and advancement programs.
PLANNING FOR CAMP
Pre-Camp Checklist
Ensure your group’s leader checks their email for pre-camp information
pertaining to your group’s camp reservation.
16 weeks before camp - Parent’s night conducted to inform parents of camp
plans
Early Spring - Watch the Camp Tifie pre-camp video on YouTube
12 weeks - Leadership arranged, two-deep leadership at all times
May 1- Half of your group’s camp fees are due to Crossroads of the West
Council
May 1 - Online merit badge registration opens
8 weeks - Remind parents that all camp attendees need health forms
8 weeks - Participants have personal equipment list
4 weeks - Health & medical record completed for each youth & adult (Parts A, B,
and C)
4 weeks - Verify all youth and adults are registered with your Troop-submit online
roster form.
4 weeks - Transportation arranged and insurance verified
4 weeks - Group camping equipment ready
1 week - Final camp fee and participant number adjustment due
1 week - Print group roster and bring with you to camp https://
www.utahscouts.org/camproster
Day of arrival - Bring: Adults & Scout Medical forms, swim check and verified
group roster to checkin at office. Be sure numbers are accurate and balance is
paid.
PROGRAM OPPORTUNITIES
Along with the great location and staff at Camp Tifie, camp programs are the
best anywhere! Scouts and leaders will be challenged to fit merit badge
courses, free- time elective activities, and special programs into a busy week of
camp. Pre- planning is essential. Check out our great programs.
Flag Ceremonies
These include fun, games, and a chance to show off your Troop spirit.
Information concerning the day’s activities will be presented and scouts will be
able to experience patriotic ceremonies and build their appreciation for our
great country.
Swim Check
Troop Service Projects
It is recommended that
groups do this at a If desired, we provide opportunities for your Unit to do service projects while in
community pool before camp. Many Troops feel this is an important part of their summer camp
arriving at camp. This experience. Projects can range from very simple to more complex. Often adults
helps speed up the with special talents can do more intricate and exacting work. The camp will
check-in process at
camp.
tailor projects to your Troops’ age and skill. We are always looking for people
who would like to help Camp Tifie become even better. Anyone interested in
joining our support team, please notify the Camp Director. All aspects of
support can be used and are greatly appreciated.
Leader’s Training
Throughout the week, our staff will provide Round Tables which are open to all
adult leaders, and the camp will also offer; Youth Protection certification, Safe
Swim Defense and Safety Afloat cards.
Buddy System Campsite Inspections
All campers should have Campsites will be inspected each day by the commissioner and Senior Patrol
a buddy while at camp. Leaders within each Commissioner area. The purpose is to improve health and
Your buddy has your safety, patrol method, and scout spirit.
back and you have your
buddies back! Watch out
for, and help each other. Campfires
There will be campfire programs for the entire camp on Monday and Friday
nights performed at Tifie’ s fabulous fire bowl next to the Burch Lodge. On
Wednesday nights, Commissioners will direct campfires where each troop will
perform for the troops assigned to each commissioner area. Check with your
Camp Friend for ideas for skits and songs to be ready to show the camp. The
Commissioner will need to review and approve all skits and songs.
PROGRAM OPPORTUNITIES Swimming Camp Tifie has a phenomenal olympic-sized swimming pool, operated in strict accordance with BSA policies and is used for general swims during free time, merit badge classes, and rank advancement instruction. Polar Bear Society This is a chance for Scouts to learn about nature by experiencing it! Membership in the Camp Tifie Polar Bear Society is open to all campers. Tifie Pentathlon The Tifie Pentathlon will include troop or patrol-based competitions in swimming, running, rifle, archery, and knot tying. Nature Area And Trail Camp Tifie offers many opportunities to discover and learn about our environment. We offer a nature trail which is set up to be staff-led or self- guided. Archery Range An archery range is available, and all participants receive safety orientation and skill training. Arrows are provided. Mile Swim This is an individual activity. Participants will need another Troop member to supervise and count laps, and will need to work with the Waterfront Director for times, locations, and equipment to be utilized. Order of the Arrow The Order of the Arrow (OA) is Scouting’s National Honor Society. A major component of the OA is camping and camp promotion. The Council’s OA Lodge, the Ammatdiio (Ah-mah-Di-yo) Lodge will have representatives available at camp to perform unit elections, or answer any questions you may have. If you are a member of the OA, bring your sash and wear it on OA day!
ACE OPPORTUNITIES The ACE program is an Advanced Camping Experience for those Scouts 14 yrs and older. FULL COPE Program At Camp Tifie their ACE program is a Full COPE program. During the merit badge class instruction time, scouts that are 14 and older can sign up to participate in the Full COPE program. This program develops COPE principles that help participants develop leadership and team building. Scouts sign up for Full Morning COPE program in place of taking merit badge classes and they will be there for three hours on Monday, Tuesday, Wednesday, Thursday, and Friday. Scouts should register online for this program. Freetime COPE Experiences Camp Tifie offers two COPE experiences during freetime. For second year campers, we offer the High COPE experience. This is a 1.5 hour session on the COPE Cube where participants will challenge themselves to complete several high COPE elements and finish with the Zip Line off the Cube. The sessions begin at 2:30 and 4:00 and signup for the sessions will happen at Scoutmaster Roundtable. We also offer the low COPE team building adventure games for any camper who would like to sign up. These are one-hour sessions that will begin at 2:30, 3:30 and 4:30. Signup for the sessions will happen at Scoutmaster Roundtable. Swimming Camp Tifie has a phenomenal olympic-sized swimming pool, operated in strict accordance with BSA policies and is used for general swims during free time, merit badge classes, and rank advancement instruction. Polar Bear Society This is a chance for Scouts to learn about nature by experiencing it! Membership in the Camp Tifie Polar Bear Society is open to all campers. Tifie Pentathlon The Tifie Pentathlon will include troop or patrol-based competitions in swimming, running, rifle, archery, and knot tying.
RANK ADVANCEMENT The primary responsibility for rank advancement is that of the unit leaders and the unit committee. Camp Tifie assists Unit leadership by providing the finest in instruction and counseling. Although staff instructors and counselors will provide accurate records for information covered and skill accomplished, it is the responsibility of each unit leader to mark rank advancements in each youth’s individual record (usually in their handbook). Camp counselors will also sign merit badge cards, but the Unit is responsible to ensure they are properly recorded in each youth’s permanent record. Advancement Policies All advancement will be in accordance with BSA National Standards. Merit badge counselors and instruction will be supervised by trained Directors, 18 years of age or older. Blue cards for completed merit badges will be provided by Camp Tifie. Those not completing all requirements for a specific merit badge will be given partial completion slips. Boards of Review may be conducted in camp if adequate adult leadership is available. Appropriate adult representation on the board, however, is the responsibility of each Unit. The Scoutmaster, Advisors or Skipper is responsible to prepare, monitor, and verify completion of the Scout’s advancement. Preparing for each merit badge by the Scout is highly encouraged and work done before camp is acceptable. Any Scout receiving a merit badge from Camp Tifie will know the subject matter and have learned the practical skills associated with the merit badge. NOTE: Unit leaders are given an opportunity to review all advancement records before leaving camp and are encouraged to review them at home and give the records and cards to the Unit Advancement Chairman. Trail to First Class Program The first year camper program at Camp Tifie is designed to provide new and young Scouts a program where they can learn basic Scout skills. Many of the skills taught will complete requirements for Tenderfoot to First Class ranks; however, we recommend that all campers participate in these activities. Activities in this program are offered during the third merit badge time slot, or are available to all Scouts during Tuesday, Thursday, and Friday free time periods. Specific requirements are posted towards the end of this guide. Merit Badge Program The following is a list of merit badges offered at Camp Tifie. Any registered merit badge counselor who would like to offer or teach additional badges while at camp is welcome. Please contact the Program Director. For all badges listed below, the camp provides staff counselors and instructors.
RANK ADVANCEMENT
Class Time Offerings
Trail to First class - Class hour #1, 2, 3
• Archery - Class hours #1, 2, 3 ($)
• Astronomy - Class hours #2, 3
• Orienteering - Class hours #2
• Rifle shooting – Class hours #1, 2, 3 ($)
• Shotgun shooting – Class hours #1, 2, 3 ($)
• Personal fitness - Class hours #3
• Sports - Class hour #1
• Lifesaving - Class hours #1, 2, 3
• Swimming - Class hours #1, 2, 3
• Emergency preparedness - Class hours #2, 3
• Environmental science - Class hours #1, 2, 3
• First aid - Class hours #1, 2, 3
• Fish & wildlife - Class #1, 3
• Forestry - Class #1, 3
• Indian lore - Class #1, 3 ($)
• Leatherwork - Class #2, 3 ($)
• Mammal study & Nature - Class #1, 2
• Pioneering - Class #1, 2
• Search and rescue - Class #2, 3
• Wilderness survival - Class hours #1, 3
• Wood Carving - Class #1, 2
• ACE - Classes #1-3
DURING “FREE TIME” the Waterfront and Archery merit badges are not offered
but all others are available with the addition of:
• Basketry ($)
• Chess
• Bird Study
• Geology
• Soil and Water Conservation
• Weather
Camping, cooking, and hiking merit badges are signed off by the Scout’s own
Unit Leaders.
Merit Badge Preparation
Some Merit Badges have requirements that cannot be completed in a week of
summer camp. If your Scouts are interested in finishing any of these at camp,
ensure the following requirements are completed prior to arriving at camp.
• Emergency Preparedness - requirements #2c and #8b
• Life Saving - Complete the Swimming Merit Badge. Know front crawl,
sidestroke, breaststroke and elementary backstroke
• Nature - requirement #4 (we can do Req. 4 options b,g, and h at camp)
• Personal Fitness - requirements #8 and #9
Requirements Required Before Arriving at Camp
• Sports - requirements #4 and #5CAMP LIFE Special Needs Requests All special medical conditions should be reported to the health officer upon arrival in camp. If there is a camper with special needs, please contact the Camp Director so we can make the appropriate accommodations. Campsite Accommodations Each campsite has a picnic table (or more) and covered pavilion. Participants and groups need to plan on bringing their own tents. We encourage groups to bring wagons or wheel barrows to get your equipment from the parking lot to your campsite. Restrooms Camp Tifie provides bathroom facilities with all flushing toilets to campers. Please do not throw any garbage down the toilets. This includes: feminine hygiene of any kind, pads, inserts, applicators, wrappers, hand wipes or baby wipes, toilet paper rolls, wrappers, candy wrappers, or food items. These items clog the septic system and prevent it from working properly. There are garbage cans in every stall, please use them. When the garbage cans get full, please empty and replace the can liners. There are extra garbage bags and toilet paper in the lodge. Water Each campsite has a nearby water spigot with potable water. Encourage your participants to stay hydrated! Ecology Please make certain that all group members understand the delicate balance of plant and animal life in the wilderness. Everyone should do their best to ensure that no animals are molested or killed - this applies to aquatic as well as land life. No pets of any kind should be brought to camp. Pets are a threat to wildlife and are in danger themselves. Never cut down a tree, dead or alive. Do not carve names or symbols into the trees or do anything else that could damage the trees. Tree Climbing Camp Tifie has a strict no tree climbing policy. Participants (youth or adult) that are discovered to be climbing trees will be sent home.
CAMP LIFE
Hammocks
Those that wish to use hammocks at camp must provide their own free-
standing frame. Adults are encouraged to ensure a hammock’s set-up is safe
for the individual using the hammock.
Camp Fires
The smallest spark is a deadly threat to wildlife and campers. No fireworks are
PETS ARE NOT
allowed in camp. Only propane fires are allowed in campsites. No wood fires
ALLOWED allowed. Restrictions are posted online at www.utahscouts.org/safety.
No pets are allowed in
camp at any time except Quiet Hours
service animals.
We are required to provide all campers with at least nine hours of quiet time.
Between 10:00 PM and 7:00 AM each day we ask that you enforce this quiet
period.
Showers
Camp Tifie’s showers are available for all youth and adults to use as they are
individual rooms with locks. Maintenance of the facility is the responsibility of
all who use it. Report any malfunctions to the Camp Director at once. Please
help everyone do their part to keep the showers clean and safe. Adults should
be aware of their group’s behavior and control discipline by providing
supervision while your group is at the shower facility. If there are any
difficulties with other campers, please contact the staff.
TRADING POST
Depending on the groups in camp each week, will depend on which bathrooms
The Trading Post is are designated for boys and which are designated for girls. This will be clearly
stocked with merit badge marked and your group will be informed at check-in which bathrooms will be
kits, snack items, drinks, designated male and female.
ice cream, candy, t-shirts
and other items. Adults will shower in the morning and youth will shower in the evening in
designated rooms based on gender, at the central showers. Individual showers
can be found in the training center and are available during all non-quiet hours.
Vehicles, Trailers, and Parking
Vehicles parked on camp property must display a camp vehicle registration
card that will allow camp staff to contact the owner/operator in the event of an
emergency or other need. These registration cards are attached to this packet.
Please do not allow anyone in the back of trucks or in trailers while transporting
equipment. Trucks, cars, vans, trailers and RVs must park in the designated
parking lots. While driving in camp, please stay below 15 MPH.
Vehicles will not be allowed at campsites except for loading and unloadingFOOD SERVICE It is our hope to serve you well while you’re at Camp Tifie. Our Staff is here to be of assistance to you. Dining Hall This service includes three balanced meals prepared by our cooks, each day. Reservations for guests must be made and paid for in advance: $8.50 per meal. Participants must be washed and wearing full uniform is encouraged for evening meals. Units will be on a rotation for after-meal cleanup. Bring Your Own Food Simple: you bring it, you prepare it, and you store it. Food storage will be your responsibility. Ice is available for purchase in the commissary for $2 per bag. When washing dishes, use hot water. It is recommended that to wash and rinse in an approved disinfectant after all meals. Allow each dish to air dry. After drying, store in a clean place. This will prevent diarrhea and other contact diseases. Dietary Restriction Accommodations If you have someone in your group who has special dietary restrictions to items posted on our menu, fill out the allergy form online at www.utahscouts.org/ allergy Please do this no later than 2 weeks prior to arriving at camp to help us meet dietary needs. If our staff have concerns about accommodating your particular allergy or dietary needs you will be contacted. Menus Menus will be posted online by early Spring.
HEALTH & SAFETY Emergency Procedures In any large-scale operation, there exists the possibility of “emergencies.” This procedure is to help the staff and leaders perform efficiently in any emergency and keep everyone informed. Weather-Related Emergencies Camp Management makes every reasonable effort to monitor weather conditions that may pose a threat to the health and safety of the camp. Leaders are ultimately responsible for the safety of their participants, and are strongly encouraged to use good judgment when a possible threat exists. Weather Impact on Activities Occasionally, camp program and activities will be impacted by weather events. In particular the COPE and Aquatics area are often the first to be impacted. Thunder & lightning in the vicinity of camp can cause us to “delay” or “cancel” these activities. We do not take your safety lightly! Decisions to close an area are usually determined by the area director, in consultation with the Camp Director. As always, we depend on our unit leaders to be aware of any weather activity that they deem may impact the safety of their participants. If you as a leader determine that you need to move your participants from an area, or move off an activity field, we encourage you to do that and not wait for a decision from the Staff. Fires Campers and staff should be careful with fire. In the event of a fire, the camp alarm will broadcast. Please make sure that everyone in your unit knows that when they hear the alarm, they should go immediately to the parade grounds outside of the lodge and assemble there. Do not try to find each other around camp. The camp administration will then provide directions about how to proceed. An emergency drill is normally held within 24 hours of each arrival group. Lost or Missing Person If a youth or adult is believed to be missing, adult leaders should first confirm that the missing person is not in the campsite, activity areas, or other common gathering places about camp. The group should utilize the following steps: Assemble Your Group, Check Each Tent, Check Areas, then if not found, notify a staff member immediately. Other Emergencies Depending upon the nature of the emergency, camp staff will communicate necessary information to the camp, based on the nature of the threat.
CAMP POLICIES
Camp Tifie follows the National BSA policies on Youth Protection. The BSA has
adopted the following policies for the safety and well-being of its members.
These policies primarily protect youth members; however, they also serve to
protect adult leaders.
Two-Deep Leadership
Two adult leaders 21 years of age or over are required at all times while at
camp. All adults in camp must be registered with the unit.
No One-On-One Contact
One-on-one contact between adults and youth members is not permitted. In
situations that require a personal conference, the meeting is to be conducted in
view of the other adults and youth.
Respect of Privacy
Adult leaders must respect the privacy of youth members in situations such as
changing clothes and taking showers at camp and intrude only to the extent
that health and safety requires. Adults must protect their own privacy in similar
situations.
Tenting Accommodations
Separate tenting arrangements must be provided for male and female adults as
well as for male and female youth.
Youth sharing tents must be no more than two years apart in age. Youth and
adults must tent separately. Spouses may share tents.
Group Discipline and Adult Supervision
The role of the camp staff is to provide the summer camp program and all of
the other camp infrastructure needed to ensure a safe and enjoyable stay at
camp. As with any group outing, the adult leadership of each group is
responsible for the behavior of their participants. Please help the staff focus on
program by watching your participants and being available to deal with
discipline issues should they develop.
Insurance
• Each group is required to carry adequate and proper liability insurance.
• Scouts BSA and Venturing members registered in the Crossroads of the
West Council are already insured - so nothing is required.
• Please prepare to verify that each camper is protected with personal
health insurance - ensure that policy numbers are listed on each medical
form.CAMP POLICIES
• Groups must have two-deep leadership at all times while at camp. No
exceptions! All adults must be registered with the unit.
• No fireworks of any kind are permitted on camp property.
• No flames, fires, or fuels of any kind are permitted inside tents.
• Throwing rocks is strictly forbidden.
• Personal firearms and bows are not permitted, please leave them at
VALUABLES home.
Please remember to • All vehicles must be parked in the designated camp parking areas. Only
safeguard your valuables authorized vehicles are allowed on the roads through camp.
while at camp.
• No alcoholic beverages or illegal substances are allowed on camp
A locked vehicle in the property.
parking lot may be used to
store your group’s
valuables.
• Shoes must be worn at all times at camp and must not be open at the
toe or sides. Sandals are allowed only at the showers.
• No sheath knives – leave them at home.
• No LASER (pens/pointers) of any kind are permitted in camp.
• All guests are required to immediately check-in at the Camp Office.
• Refer to the Boy Scouts of America Guide to Safe Scouting for
additional policies.
TECHNOLOGY • Smoking - all buildings and tents are smoke-free. There are designated
smoking areas for those who smoke.
Participants are
encouraged to • Swimwear - participants are encouraged to wear swim wear that is
appropriately document suited for active water sports such as swim trunks or board shorts for
and share their males and one-piece suits or tankinis for females.
experiences during their
stay.
Please remember, there is
no power outlets for
guests to use to charge
their devices.FREQUENTLY ASKED QUESTIONS How do I make changes to my registration including merit badge classes? The person named on the registration has access to the system to add and change participant numbers, make payments and add and change merit badges. A user ID and password is required. You can add and subtract youth to your registration and make payments online up to 5 days before your camp date. Visit “Merit Badge/Scout How to make changes" instruction sheet found at the bottom of www.utahscouts.org/tifie. The system will lock the leader out at 5 days before camp. Number changes within the 5 days must be done by the Council's service desk at 801-479-5460 or program.office@scouting.org. Any changes to merit badges within that 5 day period must be done at camp check in. When can we sign up for Merit Badges? The merit badge system goes online May 1 at 8 am. You must have your half balance owed paid and your Scouts named and added to the registration roster before the system will let you proceed. You can do that any time before May 1. If you make additions at the same time as doing the merit badge sign ups, you will need to pay the half balance with a card before the classes will save. You must go through all steps of “Check Out” to finalize your order. Be sure you get a receipt to confirm your class choices were saved and finalized. What do I do for checking out of camp? Check out: Friday afternoon/evening or Saturday a.m. Receive back health forms, camp totems and clear account. Receive link to Refund Credit Request if needed. Don't forget to go online to make your registration for next year and get your choice of camp and dates! What are the swim check requirements? Camp Tifie allows swim checks to be done prior to camp.Swim checks can be done by an adult comfortable with swimming. See Leaders Guide for swim check form/requirements. Changes: Changes and payments to registration or merit badges can be made online up to 5 days before camp. Within those 5 days changes or payments HAVE to be made through the Council's service desk. Changes to merit badges within the 5 days prior must be done at camp on day of check in. Final payments should be paid prior to camp check in. Youth added at camp will have a $10 late fee added.
FREQUENTLY ASKED QUESTIONS What do I bring for check-in? • Health and medical forms for youth and adults – Parts A,B & C. All adults in camp 72 hrs or more must have a physical (part C of health form). Note: to swim, hike and participate in most camp activities - participants (youth & adults) will need to have all 3 parts of the BSA health form (including physician physical). • Copy of registration showing paid in full. • Group roster showing all youth and adults attending – youth and leaders must be verified of BSA Scout membership at the Council office 4 weeks prior. Visit utahscouts.org/camproster to submit your roster online for verification. • Any adult in camp needs to be BSA registered prior to camp date. This includes parents. • Swim check form • Final payment – cash, check, or card. We prefer final payment be made online before camp. Can I add people to the registration at check-in? Yes, you may add additional participants at camp check-in. There will be a $10 late fee to add them. We suggest you do not pay for someone you are not sure if they are attending. Pay for them at check-in to avoid losing your fee if they do not come. Merit badges can be added at check-in. Can I get a refund if I over pay? A credit to for next years camp is possible in place of a refund. If you paid for more youth than came to camp, be sure to request a credit when you return home from camp. Be VERY specific as why the participant did not come. The online form is available at www.utahscouts.org/campcredit. You will receive a letter (emailed to whoever fills out the form) in September explaining if the request for a credit will be accepted or denied according to your reason for absence. Remember, you may adjust your numbers online up to one week before camp. Be sure your numbers are as accurate as possible to prevent over payment. Only pay for those confirmed attending. Will I receive additional information? The camp director will send out monthly emails with camp information starting in January, watch your email for that information.
Low Ropes Course
Ropes Course Center
Locked Gate
Pavilion
High Ropes Course
Pavilion
Amphitheater
Pavilion Nature Center
Burch Lodge
Handicraft
Cox Trail
Aardvark Trading Post
Alligator
Kolob Amphitheater Inouye Training
Antelope
Camp Director Cabin Center
Bobwhite Beaver Pool
Fox Elk
Parking Lion Cobra
Leopard Trail Bear
Falcon Eagle Bobcat
Hawk Panther Buffalo Staff
Leopard
Road Gate
Parade Porcupine
Mustang
Sunset Bowl Moose Grounds Showers
Amphitheater
Mt. Pleasant Osprey Raccoon
Otter Pavilion Raven
Owl Scorpion
Seagull
Outdoor Skills
Squirrel
Tiger
Wolf
Archery Range
Rifle Range
Shotgun Range
CAMP TIFIE
CROSSROADS OF THE WEST COUNCILCAMP TIFIE WEEK AT A GLANCE
6:30 7:30 8:30 9:00 9:30 10:30 11:30 12:45 2:00 3:00 4:00 5:15 7:00 7:30 8:00 8:20 8:30 9:00 10:00
Scoutmaster Check-in Class 2 SPL & SM Fire Flag Opening
Mon Swim checks (if needed) Class 1 Class 3
SM Mtg Ceremony Campfire
Set up camp Meeting Drill Q
3:15
S
Class 2 F
u
u B C F l Fellowship of the
Tues n a
Class 1 Class 3 D Scoutcraft Skills Event i
l L a Buffalo Induction
r r m SM Mtg g
i p
a Free Time i e
s e g Class 2
u C
e I
n e
t
Wed a Class 1 Class 3 n Commissioner Campfire Troop Activities
n C r
SM Mtg n
A s c e
c k p
e Troop Shoots @ Archery
e m T
t e r Class 2 h ACE Program o
Thur i
f c e Class 1 Class 3 r n Frontier Games Honor Trail i
v t m SM Mtg y
i
a i m
o
t o Scoutmaster
i
s n n Merit Badge Completion Closing e
Fri e s y Tifie Pentathlon Checkout & Flag Ceremony
s
t Time Campfire
Cobbler
Notes: Trail to First Class/First Year Camper:
Breakfast 7:30 Flag Ceremony ____________________ Mon- Pathfinder (Outdoor Skills)
Sat Clean-up campsites Tues- Commando Corps (Field Sports)
Leave camp by 10:30 Service Project ____________________ Wed- Naturalist (Nature)
Thurs- Baywatch (Aquatics)
Handicraft Nature Outdoor Skills Field Sports Aquatics Wilderness Survival Thursday @ 7:00
Wood Carving Environmental Science First Aid Sports Swimming
Indian Lore Forestry Emergency Preparedness Orienteering Lifesaving Star Party Tues & Wed @ 1- PM
Leatherwork Mammal Study Wilderness Survival Personal Fitness
Basketry Nature Pioneering Archery OA Social After Commissioner Campfire
Radio Astronomy Search & Rescue For any Scout that is in or Interested in the OA
Robotics Fish & Wildlife Trail to First Class
Bird StudyCAMP TIFIE TRAIL TO FIRST CLASS REQUIREMENT CHECKLIST
MONDAY—PATH FINDER (ORIENTEERING AREA) FRIDAY MORNING—BAY WATCH (AQUATICS)
SECOND CLASS TENDERFOOT
____3a. Demonstrate how a compass works and how to orient ____4a. Show first aid for the following: Simple cuts and
a map. Use a map to point out and tell the meaning of five scrapes, Blisters on the hand and foot, Minor (thermal/heat)
map symbols. burns or scalds (superficial, or first-degree), Bites or stings of
____3d. Demonstrate how to find directions during the day insects and ticks, Venomous snakebite, Nosebleed, Frostbite
and at night without using a compass or an electronic device. and sunburn, Choking.
FIRST CLASS ____4c. Tell what you can do while on a campout or other
____4b. Demonstrate how to use a handheld GPS unit, GPS outdoor activity to prevent or reduce the occurrence of injuries
app on a smartphone, or other electronic navigation system. or exposure listed in Tenderfoot requirements 4a and 4b.
Use GPS to find your current location, a destination of your SECOND CLASS
choice, and the route you will take to get there. Follow that ____6b. Show what to do for “hurry” cases of stopped
route to arrive at your destination. breathing, stroke, severe bleeding, and ingested poisoning.
____6d. Explain what to do in case of accidents that require
TUESDAY—COMANDO CORE (PIONEERING AREA) emergency response in the home and backcountry. Explain
TENDERFOOT what constitutes an emergency and what information you will
____3a. Demonstrate a practical use of the square knot. need to provide to a responder.
____3b. Demonstrate a practical use of two half- hitches. ____6e. Tell how you should respond if you come upon the
____3c. Demonstrate a practical use of the taut-line hitch. scene of a vehicular accident.
____3d. Demonstrate proper care, sharpening, and use of the FIRST CLASS
knife, saw, and ax. Describe when each should be used. ____7a. Demonstrate bandages for a sprained ankle and for
SECOND CLASS injuries on the head, the upper arm, and the collarbone.
____2f. Demonstrate tying the sheet bend knot. Describe a ____7b. By yourself and with a partner, show how to:
situation in which you would use this knot. Transport a person from a smoke-filled room. Transport for at
____2g. Demonstrate tying the bowline knot. Describe a least 25 yards a person with a sprained ankle.
situation in which you would use this knot. ____7c. Tell the five most common signals of a heart attack.
____3c. Describe some hazards or injuries that you might Explain the steps (procedures) in cardiopulmonary
encounter on your hike and what you can do to help prevent resuscitation (CPR).
them. ____7d. Tell what utility services exist in your home or
FIRST CLASS meeting place. Describe potential hazards associated with
____3a. Discuss when you should and should not use lashings. these utilities and tell how to respond in emergency situations.
____3b. Demonstrate tying the timber hitch and clover hitch. ____7f. Explain how to obtain potable water in an emergency.
____3c. Demonstrate tying the square, shear, and diagonal
lashings by joining two or more poles. FREETIME—BAYWATCH (AQUATICS)
____3d. Use lashings to make a useful camp gadget. (Can be done T, W, Th, or F during free time)
SECOND CLASS
____5a. Tell what precautions must be taken for a safe swim.
WED/THURSDAY—NATURALIST (NATURE AREA) ____5b. Demonstrate your ability to pass the BSA beginner
____4b. Describe common poisonous or hazardous plants; test: Jump feet first into water over your head in depth, level
identify any that grow in your local area or campsite location. off and swim 25 feet on the surface, stop, turn sharply, resume
Tell how to treat for exposure to them. swimming, then return to your starting place.
SECOND CLASS ____5c. Demonstrate water rescue methods by reaching with
____4. Identify or show evidence of at least 10 kinds of wild your arm or leg, by reaching with a suitable object, and by
animals (such as birds, mammals, reptiles, fish, or mollusks) throwing lines and objects.
found in your local area or camping location. You may show ____5d. Explain why swimming rescues should not be
evidence by tracks, signs, or photographs you have taken. attempted when a reaching or throwing rescue is possible.
FIRST CLASS Explain why and how a rescue swimmer should avoid contact
____5a. Identify or show evidence of at least 10 kinds of with the victim
native plants found in your local area or campsite location. FIRST CLASS
You may show evidence by identifying fallen leaves or fallen ____6a. Successfully complete the BSA swimmer test.
fruit that you find in the field, or as part of a collection you ____6b. Tell what precautions must be taken for a safe trip
have made, or by photographs you have taken. ____5b. afloat.
Identify two ways to obtain a weather forecast for an
upcoming activity. Explain why weather forecasts are
important when planning for an event.
____5c. Describe at least three natural indicators of impending
hazardous weather, the potential dangerous events that might
result from such weather conditions, and the appropriate
actions to take.CROSSROADS OF THE WEST COUNCIL
CAMPER RECOGNITION
FELLOWSHIP OF THE WEST FELLOWSHIP OF THE WEST FELLOWSHIP OF THE WEST
1ST YEAR CAMPER 2ND YEAR CAMPER 3RD YEAR CAMPER
REQUIREMENTS REQUIREMENTS REQUIREMENTS
Be a first-year camper at a Crossroads of the West Be a second-year camper at a Crossroads of the West Be a third-year camper at a Crossroads of the West
Council camp. Council camp. Council camp.
Participate in a troop or patrol activity. Participate in an inter-troop activity. Help to organize a patrol, troop, or intertroop activity.
Complete the camping requirements for Tenderfoot Teach a skill to another Scout using the EDGE method. Help another Scout pass off requirements for
Rank. Tenderfoot, Second Class, or First Class rank
Complete a conservation service project while at camp. advancements.
Complete a service project at camp.
Invite and participate in one or more activities with Help plan and organize a meaningful service or
Participate in free-time activities at two or more other Scouts (troop shoot, aquatic, COPE, climbing, conservation project while at camp.
program areas (aquatics, shooting sports, COPE, nature, handicraft, or outdoor skills activity).
climbing, nature, handicraft, or outdoor skills). Demonstrate improvement in a free-time activity
Participate in one unique activity opportunities requiring skill such as mile swim, dime club, top archer,
Attend at least one camp-wide activity during the (sunrise canoe, polar bear, polar plunge, sunrise hike, hiking at least 10 miles, COPE, etc.
week. etc.).
With the help of your Scoutmaster, set and accomplish
Show cooperation and willingness to follow troop Fulfill assignments on your troop or patrol duty roster a personal goal during the week at camp.
leaders while at camp. (fireguard, bear warden, KP, shower cleanup.).
Organize and lead a group of Scouts to complete an
activity or service opportunity (KP, latrines, etc.)
NAME: NAME: NAME:
SPL SM CAMP DATE SPL SM CAMP DATE SPL SM CAMP DATE2024 CAMP GEAR
Swim Check Certification
Instructions: • Complete 1 of the following:
✦ Swimmer test (S):
• This form is to be used by groups attending BSA operated facilities.
• Jump feet first into water over the head in depth, level off,
• Fill out the group contact information, and list all participants that will
and begin swimming.
attend camp (youth & adults).
• Swim 75 yards in a strong manner using one or more of the
• The swim classification (swim check) is a key element of BSA Safe
following strokes: side, breast, trudgen, or crawl.
Swim Defense & Safety Afloat. All persons participating in aquatic
• Swim 25 yards using any resting back stroke.
activities will be classified according to their swimming ability. The swim
• The 100 yards total must be done continuously and include
check allows individuals to demonstrate the minimum level of swimming
at least one sharp turn.
skill consistent with circumstances while in the water.
• After completing the test, rest by floating.
• When swim checks are conducted away from camp or at the point of
✦ Beginner test (B):
activity, the BSA certified aquatics director has the authority to review or
• Jump feet first into water over the head in depth, level off,
retest all participants to ensure standards have been maintained.
and begin swimming.
• The swim check should take place in a maximum 12 foot depth body of
• Swim 25 feet on the surface, stop, turn sharply, and resume
water. During the swim check, the swimmer must be within 25 feet of
swimming as before.
shallow water footing or pool/pier edge.
• Return to starting place.
• Administration of swim check: 1) Completed on the first day of camp by
✦ Learner (L):
aquatics personnel, 2) Completed on the group-level and conducted by
a BSA aquatics instructor, aquatics supervisor, BSA lifeguard, certified
lifeguard, swimming instructor or coach.
• Regardless of where or when the swim test is given, the following Signature of adult supervising swim test:
procedures apply: the test is given one-on-one (the test administrator
and the swimmer are buddies during the administration of the test);
each component of the test is important (the test must not be
changed); the test must be completed without aid or support (aid Who performed your swim check? Circle one:
includes: lifejackets, wetsuits, fins, etc. Swim goggles may be used to • Aquatics instructor, BSA lifeguard, certified lifeguard
avoid eye irritation); swim tests must be renewed annually • Swimming instructor, swim coach
(preferable at the begging of the outdoor season). • Swimming/Lifesaving merit badge counselor, unit leader
Unit # _______________ Camp: _________________ Camp Date: __________________
Unit Leader Name (First & Last): ____________________________________________________
Mailing address: ________________________________________ City: ________________ State: _____
ZIP: ________________ Phone: ( ___ ) ________________ Email: ______________________________
Name Swim Class Name Swim Class Name Swim Class
_________________ S B L _________________ S B L _________________ S B L
_________________ S B L _________________ S B L _________________ S B L
_________________ S B L _________________ S B L _________________ S B L
_________________ S B L _________________ S B L _________________ S B L
_________________ S B L _________________ S B L _________________ S B L
_________________ S B L _________________ S B L _________________ S B L
_________________ S B L _________________ S B L _________________ S B L
_________________ S B L _________________ S B L _________________ S B L
_________________ S B L _________________ S B L _________________ S B LTransportation
Checklist
The safety of our Scouts, volunteers, employees, and communities
is our top priority. This two part SAFE Transportation Checklist and
Pre-Trip Transporting Inspection is designed to help you manage
the risks associated with transporting Scouts.
Date: _____________________ Destination: _________________________________________________________________________________
Supervision—Youth are supervised by qualified and trustworthy adults who set the example for safety.
Two-deep leadership for duration of trip
Assessment—Activities are assessed for risk during planning.
Route is planned.
Passenger list is planned for trip, both to and from destination.
Breaks are planned.
Drive time is no more than 10 hours within a 24-hour period.
Meets or exceeds vehicle liability insurance minimums.
Passengers have seats with factory-installed seat belts.
Weather/environment contingencies and communications are planned.
If operating a 15-passenger van, manufacture date is after 2005.
Fitness and Skills—Leaders have prerequisite fitness and skill to operate vehicle.
Driver Annual Health and Medical Records are reviewed.
Driver is an adult, age 18 or over.
Driver has a valid driver’s license, a commercial license if applicable.
Driver understands expectation to follow all applicable traffic laws.
Driver is rested and not fatigued.
Driver meets training requirements to operating vehicle.
Equipment and Environment—Safe and appropriate vehicle for Scouting trip. Leaders Inspect vehicles
and monitor the environment for changing conditions.
Vehicle inspection completed.
Tires on each vehicle are no more than 6 years old.
Weather forecast and conditions.
Communication plan.
If there are any incidents:
1. Take care of the injured/find a safe place.
2. Preserve and document the evidence. Take photos if appropriate.
3. Immediately complete an incident report and notify your local council.
For more information, go to www.scouting.org/health-and-safety/incident-report/.
Resources
Guide to Safe Scouting: https://www.scouting.org/health-and-safety/gss/
SAFE: https://www.scouting.org/health-and-safety/safe/
680-696
May 2021 RevisionPre-Trip
Transportation Inspection
Motor vehicles used to transport Scouts must complete
Pre-Trip Transportation Inspection before travel for each
driver and vehicle. This includes correcting all deficiencies.
Make copies for additional drivers and vehicles.
Driver’s Information
Driver’s License Number: ______________________________ Driver’s Phone Number: ______________________________________
Vehicle Information
Make and Model: ______________________________________________________ Year: ______________________________________
Inspection Current Registration Current Insurance Current Vehicle Inspection
Vehicle Inspection
Visual Inspection Driver Adjustments Operational Test
Cleanliness Pedals Defrost
Fluid Leaks Steering Wheel Horn
Loose Parts Mirrors Brakes
Light Inspection Engine Inspection Tire Inspection
Headlights Oil Tire Pressure
Brake Lights Radiator Uneven Wear
Turn Signals Battery Tread Depth
Emergency Flasher Exhaust Spare Tire
Trailer Inspection
Trailer Gross Vehicle Weight: ____________________________________Trailer Tongue Weight: ________________________________
Vehicle Towing Capacity: _________________________________ Vehicle Max Tongue Weight: ________________________________
Vehicle has capacity to pull trailer?
Trailer overall visual inspection?
Towing ball correct size?
Safety chains connected?
Trailer breakaway connected?
Lights properly working, including taillights, clearance lights, brake lights, directional signals, hazard lights, reflectors?
Tire inspection, including spare?
Trailer’s load is properly secured?
Commercial Driver’s License (CDL)
Driver meets CDL requirements, including valid CDL, medical card, and drug testing program?
Vehicle meets all federal and state CDL requirements, including IFTA and electronic trip logs?
Pro-Trip vehicle walk-around complete by CDL standards?
Emergency
Passengers have seats with factory installed seat belts?
Triangle reflectors and flares?
First-aid kit and fire extinguisher?
Emergency water, food, blankets?
Incident reporting forms?
Form of communication?
680-696
May 2021 RevisionBSA Pre-Event Medical Screening Checklist
This is a tool to help leaders identify potentially communicable diseases in advance of event participation. The intent of this
checklist is to review with each participant their current health status both before departure and upon arrival at the event.*
Name: _________________________________ Date/Event: ____________________________________
Unit: ___________________________________ Campsite: _____________________________________
Do not participate if you have any of the following symptoms in the past 24 hours:
❏ Fever (100.4° F or greater)
❏ Vomiting
❏ Diarrhea
❏ New cough
Do not participate if you or anyone you live with has recently tested positive for COVID-19 or does not have test results back.
If you have a positive COVID-19 test, follow the CDC guidance for isolation and your personal health care provider’s
treatment recommendations.
Be responsible for your health and that of others. Isolate if you are sick. Do not attend any activity/meeting/event if you,
anyone you live with or anyone you have recently been around feel unwell. Symptoms might include:
❏ Unexplained extreme fatigue
❏ Unexplained muscle aches
❏ New rash
❏ Sore throat
❏ Open sore
Participants who are symptomatic or ill should not attend or return to an activity
until cleared by their health care provider.
*Councils are encouraged to customize this checklist with the engagement of local health authorities and their Council Health Supervisor.
680-102
2022 RevisionPart A: Informed Consent, Release Agreement, and Authorization A
Full name: ___________________________________________ High-adventure base participants:
Expedition/crew No.: _______________________________________________
Date of birth: _________________________________________ or staff position:___________________________________________________
Informed Consent, Release Agreement, and Authorization
I understand that participation in Scouting activities involves the risk of personal injury, including I also hereby assign and grant to the local council and the Boy Scouts of America, as well as their
death, due to the physical, mental, and emotional challenges in the activities offered. Information authorized representatives, the right and permission to use and publish the photographs/film/
about those activities may be obtained from the venue, activity coordinators, or your local council. videotapes/electronic representations and/or sound recordings made of me or my child at all
I also understand that participation in these activities is entirely voluntary and requires participants Scouting activities, and I hereby release the Boy Scouts of America, the local council, the activity
to follow instructions and abide by all applicable rules and the standards of conduct. 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 further authorize the
In case of an emergency involving me or my child, I understand that efforts will be made to reproduction, sale, copyright, exhibit, broadcast, electronic storage, and/or distribution of said
contact the individual listed as the emergency contact person by the medical provider and/or photographs/film/videotapes/electronic representations and/or sound recordings without limitation
adult leader. In the event that this person cannot be reached, permission is hereby given to the at the discretion of the BSA, and I specifically waive any right to any compensation I may have for
medical provider selected by the adult leader in charge to secure proper treatment, including any of the foregoing.
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 Every person who furnishes any BB device to any minor, without the express or implied permission
medical staff, camp management, and/or any physician or health-care provider involved in of the parent or legal guardian of the minor, is guilty of a misdemeanor. (California Penal Code
providing medical care to the participant. Protected Health Information/Confidential Health Section 19915[a]) My signature below on this form indicates my permission.
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, I give permission for my child to use a BB device. (Note: Not all events will include BB devices.)
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. Checking this box indicates you DO NOT want your child to use a BB device.
(If applicable) I have carefully considered the risk involved and hereby give my informed consent NOTE: Due to the nature of programs and activities, the Boy Scouts of
for my child to participate in all activities offered in the program. I further authorize the sharing America and local councils cannot continually monitor compliance of program
of the information on this form with any BSA volunteers or professionals who need to know of participants or any limitations imposed upon them by parents or medical
medical conditions that may require special consideration in conducting Scouting activities. providers. However, so that leaders can be as familiar as possible with any
limitations, list any restrictions imposed on a child participant in connection with
With appreciation of the dangers and risks associated with programs and activities, on my programs or activities below.
own behalf and/or on behalf of my child, I hereby fully and completely release and waive
any and all claims for personal injury, death, or loss that may arise against the Boy Scouts List participant restrictions, if any: None
of America, the local council, the activity coordinators, and all employees, volunteers,
related parties, or other organizations associated with any program or activity. ________________________________________________________
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 Scout Ranch, Philmont Training Center, Northern Tier, Sea Base, or the Summit Bechtel Reserve, I have also read and understand the supplemental risk advisories, 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. If the participant is under the age of 18, a
parent or guardian’s signature is required.
Participant’s signature: ____________________________________________________________________________________________ Date: ______________________________
Parent/guardian signature for youth: __________________________________________________________________________________ Date: ______________________________
(If participant is under the age of 18)
Complete this section for youth participants only:
Adults Authorized to Take Youth to and From Events:
You must designate at least one adult. Please include a phone number.
Name: _________________________________________________________________ Name: _________________________________________________________________
Phone: _________________________________________________________________ Phone: _________________________________________________________________
Adults NOT Authorized to Take Youth to and From Events:
Name: _________________________________________________________________ Name: _________________________________________________________________
Phone: _________________________________________________________________ Phone: _________________________________________________________________
680-001
2019 PrintingPart B1: General Information/Health History B1
Full name: ___________________________________________ High-adventure base participants:
Expedition/crew No.: _______________________________________________
Date of birth: _________________________________________ or staff position:___________________________________________________
Age: ____________________________ Gender: __________________________ Height (inches): ___________________________ Weight (lbs.): ____________________________
Address: _________________________________________________________________________________________________________________________________________
City: ___________________________________________State: ____________________________ ZIP code: __________________ Phone: ______________________________
Unit leader: ____________________________________________________________________________ Unit leader’s mobile #: _________________________________________
Council Name/No.: _______________________________________________________________________________________________________Unit No.: ____________________
Health/Accident Insurance Company: ________________________________________________________ Policy No.: ___________________________________________________
Please attach a photocopy of both sides of the insurance card. If you do not have medical insurance, enter “none” above.
In case of emergency, notify the person below:
Name: ______________________________________________________________________________Relationship: ___________________________________________________
Address: _________________________________________________________________ Home phone: _________________________ Other phone: _________________________
Alternate contact name: _________________________________________________________________ Alternate’s phone: ______________________________________________
Health History
Do you currently have or have you ever been treated for any of the following?
Yes No Condition Explain
Diabetes Last HbA1c percentage and date: Insulin pump: Yes No
Hypertension (high blood pressure)
Adult or congenital heart disease/heart attack/chest pain (angina)/
heart murmur/coronary artery disease. Any heart surgery or
procedure. Explain all “yes” answers.
Family history of heart disease or any sudden heart-related
death of a family member before age 50.
Stroke/TIA
Asthma/reactive airway disease Last attack date:
Lung/respiratory disease
COPD
Ear/eyes/nose/sinus problems
Muscular/skeletal condition/muscle or bone issues
Head injury/concussion/TBI
Altitude sickness
Psychiatric/psychological or emotional difficulties
Neurological/behavioral disorders
Blood disorders/sickle cell disease
Fainting spells and dizziness
Kidney disease
Seizures or epilepsy Last seizure date:
Abdominal/stomach/digestive problems
Thyroid disease
Skin issues
Obstructive sleep apnea/sleep disorders CPAP: Yes No
List all surgeries and hospitalizations Last surgery date:
List any other medical conditions not covered above
680-001
2019 PrintingYou can also read
