CAMP TRACY CUB FAMILY - #WEOWNADVENTURE
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CAMP TRACY
2021
CUB FAMILY
ADVENTURE
#WEOWNADVENTURETable of Contents
Introduction to Camp .............................................................3
Non-Discrimination Clause ............................................................................3
Contact Us......................................................................................................3
Program Adventures ...............................................................4
Sensei Shooting Range (BB Guns) … ............................................................4
Kyudo (Archery) … ........................................................................................4
Imperial Palace Gardens (Nature Walk) … ...................................................4
Tsunami Bay - Yakatabune (Rowboats)… ......................................................4
Olympic Village (Trading Post) and Games … ..............................................5
Astronomy … .................................................................................................5
John Colter Run … ........................................................................................5
Campfire Program ….....................................................................................5
Honor Trail … ...............................................................................................5
General Information ...............................................................6
Arriving at Camp ...........................................................................................6
Medical Forms ................................................................................................6
Refund Policy .................................................................................................6
Insurance ........................................................................................................6
Leadership Roles & Adult Supervision...........................................................6
Camping Areas ...............................................................................................7
Hammocks......................................................................................................7
Quiet Hours ...................................................................................................7
Emergency Alarm ..........................................................................................7
First Aid ..........................................................................................................7
PAGE 1Youth Protection .............................................................................................7
Buddy System .................................................................................................8
Tree Climbing ................................................................................................8
Fire..................................................................................................................8
Firearms, Ammunition & Archery .................................................................8
Smoking, Alcohol & Drugs .............................................................................8
Lost Camper Prevention ................................................................................8
Facilities and Equipment ................................................................................9
Phone ..............................................................................................................9
Trading Post ...................................................................................................9
Food Service ...................................................................................................9
Dietary Accommodations .............................................................................10
Showers & Restrooms ...................................................................................10
Packing List ..................................................................................................10
PAGE 2Introduction to Camp
Camp Tracy is excited to offer its newest program in 2021 - Cub Family
Adventure! The Cub Family Adventures offers a three-day and two-night program
for Cub Scouts and Webelos Scouts - with their entire family (yes, siblings and
parents are invited) or Pack!
Camp Tracy is a magical place nestled in Millcreek Canyon - only minutes from
Salt Lake City, Utah.
Non-Discrimination Clause
Camp Tracy does not discriminate against anyone on the basis of race, color,
national origin, religion, age, sex, handicap, or any other delineation of peoples.
Contact Us
We’re here to help your unit have the most memorable experience at camp. If you
have any questions as you prepare for your adventure, please let us know at
program.office@scouting.org.
PAGE 3Program Adventures
Adventures include:
Sensei Shooting Range (BB Guns) …
Sensei is the Japanese word for a teacher or a master of a skill. Come and learn
from our sensei of BB Guns! Obtain gun safety and rules will be taught, and skills
will be practiced at the BB gun range.
Kyudo (Archery) …
Learn Bow and arrow safety rules, and how to shoot. Practice several times and
master your skills to become an expert marksman.
Gaga - Ball …
Experience the thrill of a game of gaga – ball. It is a fast paced, high-energy
version of Dodgeball! Of course, we would love to see gaga ball included in the
Summer Olympics! It combines so many of the other skills that make Olympic
sports exciting–jumping, dodging, swinging, kicking.
Imperial Palace Gardens (Nature Walk) …
There will be lots of exploring in this area. Participants will learn about birds,
reptiles, and all sorts of crawly creatures! The best animal wranglers will be on-
hand to further adventure and answer any questions participants may have. Leave
No Trace rules the and guidelines will be taught and followed.
Tsunami Bay - Yakatabune (Rowboats)…
In Japanese the word for rowboat is Yakatabune. Glide on the smooth waters of
Camp Tracy's pond. Participants will learn water safety and will be watched over
by our trained lifeguards. Be sure to watch for the record-sized trout that call our
pond home!
PAGE 4Olympic Village (Trading Post) and Games …
Come and visit our well stocked gift shop. There you will find all kind of snacks,
candy bars, ice cream bars, toys and other souvenirs to take home to remember the
fun you had at Camp Camp Tracy.
Astronomy …
Participants will be able to learn about the night’s skies during the evening. What
stars and constellations will you be able to discover?
John Colter Run …
This competitive relay race around camp will test groups on their Scouting abilities
and teamwork. This event will take place Friday evening.
Campfire Program …
There will be a campfire program for the entire camp on Thursday night at the fire
bowl near the Layton Lodge - skits will be performed by the camp staff. On Friday
night, groups will be able to use the gathering spaces to have their own campfire
program.
Honor Trail …
On Friday evening, groups may choose to participate in the Honor Trail. This will
be an opportunity for your group to reflect on the points of the Scout Oath & Law.
PAGE 5General Information
Please understand that the purpose of camp rules is to ensure the safety and
convenience of all those who will be living together here at Camp Tracy. These
rules make it possible for us to safely do things we would otherwise never attempt.
In a very real sense, these rules set us free.
Arriving at Camp
Plan to arrive at camp no later than 3pm on Thursday afternoon. This
will allow your group to check in, find your camping area, and attend flag
ceremony.
Medical Forms
All participants (youth & adults) must complete parts A & B of the BSA health
form. Bring these forms with you and turn them in at check in.
Refund Policy
A complete list of required deposits, fee schedules, and information about refunds
is available online at www.utahscouts.org/refund.
Insurance
• Cub Scouts 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.
Leadership Roles & Adult Supervision
Each youth member will be under the supervision of a parent or legal guardian.
Packs that attend will need to ensure each youth is accompanied by a parent.
Families that attend will need to ensure a parent is present with their youth at all
times.
PAGE 6Camping Areas
Each group participating in Camp Tracy’s Cub Scout Family Adventure will be
assigned a camping area. Each area will have spaces for setting up a tent, a picnic
table, nearby drinking water faucet and restrooms.
Hammocks
Those that wish to use hammocks at camp must provide their own free-standing
frame. Hammocks are not allowed to be attached to trees. Adults are encouraged
to ensure a hammock’s set-up is safe for the individual using the hammock.
Quiet Hours
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.
Emergency Alarm
As part of our flag ceremony, we will demonstrate the camp’s emergency alarm.
Any other alarms during the activity will be real. If you hear the alarm, walk to
the flag pole, join with your group, and ensure all are accounted for. Further
instructions will be presented at the flag pole.
First Aid
Our Health Lodge is designed to meet the emergency needs of our campers. All
injuries must be reported and properly recorded. We are ready with emergency
support and will make necessary contact with local Emergency Medical Services.
We will store all medications that require refrigeration and will assist with
dispensing if needed.
Youth Protection
The Boy Scouts of America is a leader in the fight against child abuse. We must do
everything in our power to prevent physical, emotional, and sexual abuse. To
protect youth and adults we must be extremely careful to follow the BSA TWO-
DEEP LEADERSHIP policies. The BSA cannot tolerate any activity that can, in
PAGE 7anyway, be interpreted as abusive. If you are aware of anything questionable,
please report it at once to the Camp Director. Do not become directly involved
unless there is an immediate physical threat.
Buddy System
All campers should use the buddy system at ALL times in camp.
Tree Climbing
Camp Tracy has a strict no tree climbing policy. Participants (youth or adult) that
are discovered to be climbing trees will be sent home.
Fire
The smallest spark is a deadly threat to wildlife and campers. No fireworks are
allowed in camp. All fires must be confined to the designated fire pits in each
campsite.
Firearms, Ammunition & Archery
Camp Tracy has adequate equipment and so it is required that no personal
firearms, archery equipment or ammunition be brought to camp.
Smoking, Alcohol & Drugs
All buildings and tents are smoke-free. There are designated smoking areas for
those who smoke. As a facility of the Boy Scouts of America, possession or
consumption of alcoholic beverages is not permitted on the property. Possession of
unprescribed drugs, or abuse of prescribed drugs, are expressly prohibited at camp.
Individuals or groups found in violation of this policy will be sent home
immediately.
Lost Camper Prevention
One should never go where they do not know and one should always take a buddy.
Stay on trails, in camp, or with an experienced staff guide. No one should ever go
anywhere without telling group leaders where they are going and when they intend
to return. Always be prepared with water and proper clothing.
PAGE 8Group leadership should report immediately if someone does not show up when
and where they should. Please instruct all scouts and leaders to stop and stay put,
“hug a tree”, the moment they realize they are lost.
Facilities and Equipment
Camp Tracy provides all groups with the opportunity to avail themselves of
literally hundreds of thousands of dollars worth of program equipment during a
week of camp. Normal “wear and tear” of equipment is expected; however,
careless or intentional mistreatment of equipment is not permitted. All campers
should take care of, and have respect for, all camp wide equipment and facilities
including: All shower and restroom facilities, camp wide buildings and structures,
personal camp equipment belonging to others, program equipment.
Camp Tracy is proud of its equipment and facilities. All campers are politely asked
to use the equipment as intended and to have a great time in doing so.
Phone
There is no public phone available. If there is an emergency, call Camp Tracy at
(801) 476-4819.
Trading Post
Camp Tracy has a great store, which provides camp gear, snacks, souvenirs, and
program supplies. Some other items available are soda, treats, and camp
memorabilia.
Food Service
All meals will be provided and cooked by the camp staff. Meal service will begin on
Thursday evening with dinner. On Friday, all meals will be served. The last meal
you’ll receive will be Saturday’s breakfast.
Youth and leaders will need to bring a water bottle to camp. There are multiple
trash cans placed around camp for garbage. Please remember to practice Leave
No Trace and leave the camp better than you found it.
PAGE 9Dietary Accommodations
If you have special dietary needs while at camp, please submit the “Allergies At
Camp” form at least two weeks prior to your arrival. The form can be found at:
www.utahscouts.org/allergy. We are happy to do our best to meet your needs. The
camp cook will contact you prior to your arrival at camp to consult with you and
provide you with information about our menu and which accommodations will be
available. We cannot guarantee accommodations will be 100% free from cross-
contamination as all food is prepped in the same area, but we will do our best.
Showers & Restrooms
The centralized shower house provides showers for all campers. 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.
Health, safety and cleanliness are everyone’s responsibility.
Please only put paper waste into the toilets - never any sanitary wipes or garbage.
Packing List
Please consult your Boy Scout handbook for a list of items to bring to camp. Other
resources include: http://boyslife.org/outdoors/outdoorarticles/6976/scout-
outdoor-essentials-checklist/
PAGE 10Camp Tracy 2021 – Cub & Webelos Overnight Camp Schedule
“Catch the Olympic Spirit”
Thursday Friday
3:00 PM – 3:45 PM Leader Check-in at Lodge & Scout Games 7:30 AM – 8:30 AM Breakfast
3:45 PM – 4:00 PM Opening Flag Ceremony 8:45 AM – 9:00 AM Flag Ceremony
4:00 PM – 4:45 PM Station 1 9:00 AM – 9:45 AM Station 3
4:45 PM – 5:30 PM Station 2 9:45 AM – 10:30 AM Station 4
5:30 PM – 6:30 PM Dinner 10:30 AM – 11:15 AM Station 5
6:30 PM – 7:30 PM Set up campsite 11:15 AM – 12:00 PM Station 6
7:30 PM – 7:45 PM Flag Ceremony 12:00 PM – 1:00 PM Lunch
7:45 PM – 8:30 PM Campfire Program 1:00 PM – 1:45 PM Station 7
10:00 PM – 10:20 PM Astronomy 1:45 PM – 2:30 PM Station 8
10:30 PM Lights Out 2:30 PM – 5:30 PM Free Time
5:30 PM – 6:30 PM Dinner
Saturday 6:30 PM – 7:30 PM John Colter Run
7:30 AM – 8:30 AM Breakfast 7:30 PM – 8:15 PM Campfire or Honor Trail
8:45 AM – 9:00 AM Flag Ceremony 10:00 PM – 10:20 PM Astronomy
9:00 AM – 10:30 AM Hike 10:30 PM Lights Out
10:30 AM Clean-up Camp & Drive Home
During Free Time, we offer three classes in addition
At the Adventure Stations, we offer two classes. opening up the other areas.
Please pick one of the two classes to attend.
Castaway – Elective (Building in front of BB Guns)
Adventure Earth Rocks – Elective (At the pavilion)
Castaway – Elective (Building in front of BB Guns) First Responder – Required ( )
Earth Rocks – Elective (At the pavilion)
Astronomy – Will be offered in the evening
Rotation Schedule by Group/Name
Team USA Team Canada Team Japan Team Australia
BB Guns Archery Nature Aquatics
Archery Nature Aquatics Gaga Ball
Nature Aquatics Gaga Ball Climbing Wall
Aquatics Gaga Ball Climbing Wall Trading Post
Gaga Ball Climbing Wall Trading Post Adventure
Climbing Wall Trading Post Adventure BB Guns
Trading Post Adventure BB Guns Archery
Adventure BB Guns Archery Nature
Team Russia Team Jamaica Team France Team Switzerland
Gaga Ball Climbing Wall Trading Post Adventure
Climbing Wall Trading Post Adventure BB Guns
Trading Post Adventure BB Guns Archery
Adventure BB Guns Archery Nature
BB Guns Archery Nature Aquatics
Archery Nature Aquatics Gaga Ball
Nature Aquatics Gaga Ball Climbing Wall
Aquatics Gaga Ball Climbing Wall Trading PostTracy – 2021 Cub Scout Day Camp
Note: Items that are struck through need to be accomplished at home.
Below is a list of what could be done during Day Camp this year – sometimes due to time or other reasons they may not
all be done so please keep track of what is done at each station.
Make sure each participant DID these before you sign them off. Leaders please help out as much as possible at each
station. This is your chance to make sure they are able to pass things off.
You are the leader; you will need to help the participants during each station. Be involved in the experience, help out
where and when needed.
Station 1: Sensei Shooting Range - (BB Gun Range)
Station 2: Kyudo - (Archery Range)
Station 3: Imperial Palace Garden Walk – (Nature Trail)
Station 4: Tsnami Bay - Yakatabune - (Rowboats)
Station 5: Gaga Ball
Station 6: Olympic Village - (Trading Post)
Station 7: Mount Fuji – (Climbing Wall)
Pre-Camp (Completed by the Pack)
Lion:
• Mountain Lion
o Requirement 1. Gather the outdoor items you need to have with you when you go on an
outdoor adventure and understanding how they are used. Also understand and commit to
practicing the buddy system.
Wolf:
• Call of the Wild
o REQUIREMENT 1C. Attend day camp
o REQUIREMENT 2. List possible weather changes, and how to be prepared for each.
Bear:
• Bear Necessities
o REQUIREMENT 1C. Attend day camp
o REQUIREMENT 2. Make a list of items that you should take along on the activity selected in
Requirement 1
o REQUIREMENT 3. Make a list of equipment that the group should bring along in addition to
each Scout‘s personal gear for the activity selected in Requirement 1.
During-Camp (Completed by the Pack)
Wolf
• Paws on the Path
o REQUIREMENT 5. Go on a 1-mile (you and your Scouts will walk a mile plus while at camp) hike
with your den or family. Find two interesting things that you have never seen
before and discuss with your den or family.
o REQUIREMENT 6. Name two birds, two insects, and/or two other animals that live in your area.
Explain how you identified them.Bear:
• Fur, Feathers, and Ferns
o REQUIREMENT 1. While walking a mile (you and your Scouts will walk a mile plus while at
camp) identify six signs that any mammals, birds, insects, reptiles or plants
are living near the place where you choose to hike or walk.
• Paws in Action
o Requirement 4A. Do a cleanup project that benefits your community (clean up liter found while
walking at camp)
During-Camp (Led by the Camp Tracy staff)
Station: Trading Post
Bear:
• A Bear Goes Fishing
o REQUIREMENT 3. Learn about fishing equipment and make a simple fishing pole. Practice
casting at a target
• Bear Claw
o REQUIREMENT 1. Learn about three common designs of pocketknives.
o REQUIREMENT 2. Learn knife safety and earn your Whittling Chip.
Station: BB Guns
Wolf:
• Cubs Who Care
o REQUIREMENT 1. With other members of your den, try using a wheelchair or crutches, and
reflect on the process.
o REQUIREMENT 2. Learn about a sport that has been adapted so that people in wheelchairs or
with some other physical disability can play and tell your den about it.
o REQUIREMENT 3. Learn about “invisible” disabilities. Take part in an activity that develops an
understanding of invisible disabilities.
Station: Archery
Lions:
• Rumble in the Jungle
o REQUIREMENT 1. Play a game with rules; indicate an understanding of the rules and why it is
important to follow the rules while playing the game.
Tiger:
• Earning Your Stripes
o REQUIREMENT 5. Play a game with your den. Then discuss how your den played
politely.
Wolf:
• Running with the Pack
o REQUIREMENT 4: Play a sport or game with your den or family and show good sportsmanship.
Station: Gaga BallLion:
• Lion’s Honor
o REQUIREMENT 4. Show teamwork and good sportsmanship by playing a game with your den.
Tiger:
• Earning your stripes
o REQUIREMENT 5. Play a game with your den. Then discuss how your den played politely.
Wolf:
• Running with the Pack
o REQUIREMENT 4. Play a sport or game with your den or family and show good sportsmanship.
Station: Nature
Tiger:
• My Tiger Jungle
o REQUIREMENT 1. With your parent/guardian or other caring adult (referred to in the handbook
as “your adult partner”), go for a walk outside, and pick out two or more
sights or sounds of “nature” around you. Discuss with your partner or den.
• Tigers in the Wild
o REQUIREMENT 2. Go for a short hike with your den or family and carry your own gear. Show
you know how to get ready for this hike.
o REQUIREMENT 3A. Listen while your leader reads the Outdoor Code. Talk about how you can
be clean in your outdoor manners.
o REQUIREMENT 3B. Listen while your leader reads the Leave No Trace Principles for Kids. Discuss
why you should “Trash Your Trash.”
o REQUIREMENT 3C. Apply the Outdoor Code and Leave No Trace Principles for Kids on your Tiger
den and pack outings.
Lion:
• Mountain Lion
o Requirement 3. Demonstrate an understanding of respect for animals and nature when
participating in a learning hike.
Wolf:
• Code of the Wolf
o REQUIREMENT 2. Complete one of the following:
§ A. With other members of your den or family, identify three different types of shapes
that you see in nature
• Call of the Wild
o REQUIREMENT 3
§ A. Recite the Outdoor Code with your leader.
§ B. Recite the Leave No Trace Principles for Kids with your leader. Talk about how these
principles support the Outdoor Code.
• Paws on the Path
o REQUIREMENT 4. Before hiking, recite the Outdoor Code and the Leave No Trace Principles for
Kids with your leader. (This may be combined with Requirement 3 of The Call
of the Wild Adventure.)
Bear:• Fur, Feathers, and Ferns
o REQUIREMENT 3. Name one animal that has become extinct in the last 100 years and one
animal that is currently endangered. Explain what caused their declines.
o REQUIREMENT 4. Observe wildlife from a distance. Describe what you saw. (This will depend
on the day. Encourage your scouts to view animals while in nature).
Station: Rowboats
Tiger:
• Floats and Boats
o REQUIREMENT 7. Show that you can put on and fasten a life jacket correctly.
Wolf:
• Spirit of the Water
o REQUIREMENT 4. Explain the safety rules that you need to follow before participating in
swimming or boating.
Bear:
• Salmon Run
o REQUIREMENT 3. Explain the safety rules that you need to follow before participating in
boating
o REQUIREMENT 4. Identify the safety equipment needed when going boating.
o REQUIREMENT 5. Demonstrate correct rowing or paddling form. Explain how rowing and
canoeing are good exercise.Tracy – 2021 Webelos Day Camp
Scouts will attend every station below. During the Adventure Station, scouts and leaders will select one of
the two Adventure classes to join during this station.
Below is a list of what could be done during Day Camp this year – sometimes due to time or other reasons they may not
all be done so please keep track of what is done at each station.
Make sure each participant DID these before you sign them off. Leaders, please help out as much as possible at each
station. This is your chance to make sure they are able to pass things off.
You are the leader, you will need to help the participants during each station. Be involved in the experience, help out
where and when needed.
Station 1: Sensei Shooting Range - (BB Gun Range)
Station 2: Kyudo - (Archery Range)
Station 3: Imperial Palace Garden Walk – (Nature Trail)
Station 4: Tsnami Bay - Yakatabune - (Rowboats)
Station 5: Adventure
Station 6: Olympic Village - (Trading Post)
Station 7: Mount Fuji – (Climbing Wall)
Requirement During Camp:
Arrow of Light Adventure: Outdoor Adventurer:
• Option B
o 1. With the help of your den leader or family, plan and participate in an outdoor activity.
Station: Aquanaut
• REQUIEMENT 2. Discuss the importance of learning the skills you need to know before going boating.
Station: BB Guns
• Aware and Care – Elective
o 2. Engage in an activity that simulates mobility impairment. Alternatively, take part in an
activity that simulates dexterity impairment.
o 3. With your den, participate in an activity that focuses on the acceptance of differences in
general.
Station: Archery
• Sports – Elective (Combined with Stronger, Faster, Higher)
o 3. Complete the following requirements:
§ A. Explain what good sportsmanship means.
§ B. Role-play a situation that demonstrates good sportsmanship.
§ C. Give an example of a time when you experienced or saw someone showing good
sportsmanship.
Station: Nature• Into the Woods - Elective
o 1. Identify two different groups of trees and the parts of a tree.
o 2. Identify four trees common to the area where you live. Tell whether they are native to your
area. Tell how both wildlife and humans use them.
o 3. Identify four plants common to the area where you live. Tell which animals use them and for
what purpose.
o 6. Explain how the growth rings of a tree trunk tell its life story. Describe different types of tree
bark and explain what the bark does for the tree.
• Into the Wild - Elective
o 4. Learn about the bird flyways closest to your home. Find out which birds use these flyways.
o 5. Watch at least four wild creatures (reptiles, amphibians, arachnids, fish, insects, or mammals)
in the wild. Describe the kind of place (forest, field, marsh, yard, or park) where you saw them.
Tell what they were doing.
o 6. Identify an insect, reptile, bird, or other wild animal that is found only in your area of the
country. Tell why it survives in your area.
o 7. Give examples of at least two of the following:
§ A. A producer, a consumer, and a decomposer in the food chain of an ecosystem
§ B. One-way humans have changed the balance of nature
§ C. How you can help protect the balance of nature
o 8. Learn about aquatic ecosystems and wetlands in your area. Talk with your Webelos den
leader or family about the important role aquatic ecosystems and wetlands play in supporting
life cycles of wildlife and humans, and list three ways you can help.
Gaga Ball:
• Sports:
o REQUIREMENT 1. Show the signals used by officials in one of these sports: football, basketball,
baseball, soccer, or hockey.
o REQUIREMENT 2. Participate in two sports, either as an individual or part of a team.
o REQUIREMENT 3. Complete the following requirements:
• A. Explain what good sportsmanship means.
• B. Role-play a situation that demonstrates good sportsmanship.
• C. Give an example of a time when you experienced or saw someone
showing good sportsmanship.
Station: Adventure
• Earth Rocks - Elective
o 1. Do the following:
§ A. Explain the meaning of the word “geology.”
§ B. Explain why this kind of science is an important part of your world.
o 3. Do the following:
§ B. With a magnifying glass, take a closer look at your collection. Determine any
differences between your specimens.
o 5. Identify on a map of your state some geological features in your area.
o 6. Do the following:
§ A. Identify some of the geological building materials used in building your home.
• Castaway - Elective
o 1. Complete A and your choice of B or C.§ C. Using tree limbs or branches that have already fallen or been cut, build a shelter that
will protect you overnight
o 2. Do all of the following.
§ A. Learn what items should be in an outdoor survival kit that you can carry in a small bag
or box in a day pack. Assemble your own small survival kit and explain to your den
leader why the items you chose are important for survival.
§ C. Discuss what to do if you become lost in the woods. Tell what the letters “S-T-O-P”
stand for. Tell what the universal emergency signal is. Describe three ways to signal for
help. Demonstrate one of them. Describe what you can do to help rescuers find you.
§ D. Make a list of four qualities you think a leader should have in an emergency and why
they are important to have. Pick two of them and act them out for your den. Describe
how each relates to a point of the Scout Law. Describe how working on this adventure
gave you a better understanding of the Boy Scout motto.CAMP
tracy
ROPES
COURSE
CABIN #1
CAMP SITE
CABIN #2
CABIN #3
CAMP SITE
GATE H
ARCHERY
RANGE
PARKING CAMP SITE
RIFLE
LOT RANGE
NATURE
LODGE
TRADING
POST AMPHITHEATER
GATE G
PAVILION
CAMP POOL
RANGER
STORAGE
BUILDING
CABIN #4
GATE F
LAYTON LODGE CABIN #5
AMPHITHEATER
CLASSROOM
TAYLOR CABIN #6
LAKE
CABIN #7
CABIN #8
CABIN #9
AMPHITHEATERDay Camp
Group Roster
Instructions:
• This form is to be used by units attending Day Camp programs and to be submitted at camp during check-in.
• Complete the form by listing the youth that will attend Day Camp programs.
• For Cub Scout groups: Verify BSA membership registration for each youth and adult through local BSA Service Center. This must be
verified: in person, emailed (program.office@scouting.org), at least 2 days prior to attending camp.
• Attach receipt for payments made within 7 days prior to arrival.
Unit # _________ Camp: _________________ Camp Date: __________ District: __________________
Unit Leader Name (First & Last): ___________________________________________________________
Mailing address: ________________________________________ City: ________________ State: _____
ZIP: ________________ Phone: ( ___ ) ________________ Email: ______________________________
Adult Leader Names & Email
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Youth Names & Parent’s Email
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All youth & adults that attend camp must be registered members of the Boy Scouts of America. If a youth or adult is not currently
registered when this roster is verified, a digital BSA Membership Form will be emailed to the individual(s).Part 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 PrintingPart B2: General Information/Health History B2
Full name: ___________________________________________ High-adventure base participants:
Expedition/crew No.: _______________________________________________
Date of birth: _________________________________________ or staff position:___________________________________________________
Allergies/Medications
DO YOU USE AN EPINEPHRINE YES NO DO YOU USE AN ASTHMA RESCUE YES NO
AUTOINJECTOR? Exp. date (if yes) ___________________________ INHALER? Exp. date (if yes) ___________________________________
Are you allergic to or do you have any adverse reaction to any of the following?
Yes No Allergies or Reactions Explain Yes No Allergies or Reactions Explain
Medication Plants
Food Insect bites/stings
List all medications currently used, including any over-the-counter medications.
Check here if no medications are routinely taken. If additional space is needed, please list on a separate sheet and attach.
Medication Dose Frequency Reason
YES NO Non-prescription medication administration is authorized with these exceptions: ________________________________________________________________
Administration of the above medications is approved for youth by:
_______________________________________________________________________ / _______________________________________________________________________
Parent/guardian signature MD/DO, NP, or PA signature (if your state requires signature)
Bring enough medications in sufficient quantities and in the original containers. Make sure that they are NOT expired, including inhalers and EpiPens. You SHOULD NOT STOP taking
any maintenance medication unless instructed to do so by your doctor.
Immunization
The following immunizations are recommended. Tetanus immunization is required and must have been received within the last 10
years. If you had the disease, check the disease column and list the date. If immunized, check yes and provide the year received. Please list any additional information about your
medical history:
Yes No Had Disease Immunization Date(s)
_________________________________________
Tetanus
_________________________________________
Pertussis
_________________________________________
Diphtheria
_________________________________________
Measles/mumps/rubella
Polio DO NOT WRITE IN THIS BOX.
Review for camp or special activity.
Chicken Pox
Reviewed by: ___________________________________________
Hepatitis A
Date: _________________________________________________
Hepatitis B
Further approval required: Yes No
Meningitis
Reason: _______________________________________________
Influenza
Approved by:____________________________________________
Other (i.e., HIB)
Date: _________________________________________________
Exemption to immunizations (form required)
680-001
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