PERSONAL HEALTH AND MEDICAL RECORD
CLASS 1 AND CLASS 2
Class 1 (update annually for all participants). Activity: Day camp, overnight hike, or other programs not exceeding 72 hours,
with level of activity similar to that of home or school. Medical care is readily available. Current personal health and medical
summary (history) is attested by parents to be accurate. This form is filled out by all participants and is on file for easy reference.
Class 2 (required once every 36 months for all participants under 40 years of age). Activity: Resident camp or any other
activity such as backpacking, tour camping, or recreational sports involving events lasting longer than 72 consecutive hours,
with level of activity similar to that at home or school. Medical care is readily available.
If your child has had a medical evaluation (physical examination) within the last 36 months, a copy of the results of this exami-
nation must be attached to the health history for all participants in a camping experience lasting longer than 72 consecutive hours.
If a copy is not available, a physical examination (using the Class 2 section of this form) must be scheduled by a *licensed health-
care practitioner. This medical evaluation (physical examination) also is required if your child is currently under medical care, takes
a prescribed medication, requires a medically prescribed diet, has had an injury or illness during the past 6 months that limited
activity for a week or more, has ever lost consciousness during physical activity, or has suffered a concussion from a head injury.
* Examinations conducted by licensed health-care practitioners, other than physicians, will be recognized for BSA purposes in
those states where such practitioners may perform physical examinations within their legally prescribed scope of practice.
THIS FORM IS NOT TO BE USED BY ADULTS OVER 40, BY HIGH-ADVENTURE PARTICIPANTS (USE FORM
NO. 34412A), OR FOR NATIONAL SCOUT JAMBOREE (USE FORM NSJ-34412-01).
CLASS 1 PERSONAL HEALTH AND MEDICAL HISTORY
(To be fi