Who Needs a Completed Medical Form?
Medical forms are found on the bottom of this page. Please use only the medical forms found on this site (Camp Workcoeman 2019 Printing) and not those from the CRC or any other site.
All Scouts and Scouters staying at camp more than 72 hours (consecutive or non-consecutive) need parts A, B, C, and D of the CW version of the BSA Annual Health and Medical Record form completed and submitted along with any applicable Medication Administration and Food Allergy Treatment Plan forms. For those staying less than 72 hours, Part C is not required.
Scouts with Special Needs
If a Scout has a Care Plan for school please provide a copy of it with the medical form so any accommodations can be facilitated. The information is kept confidential on a need to know basis. If a food accommodation is required please complete the Food Accommodation Request form also.
Please use only the medical forms found on this site. Forms published prior to the 2019* printing (bottom right corner) cannot be accepted. The medical form linked from this page can be filled out on the computer using Adobe Reader; many items auto-fill after you enter them the first time. (* for physicals on or after 01/01/2020)
All four parts of the BSA form must be completed and submitted along with any applicable Authorization for Administration of Medication, Emergency Treatment Plan for Allergic Reactions, and/or Camp Food Accommodation Request forms.
Part A: Informed Consent, Release Agreement, and Authorization
- This form is the permission for the camper to participate in camp activities as well as stipulates who may or may not remove the camper from camp.
Part B1: General Information/Health History (Page 1)
PLEASE NOTE: This information must be completed even if you are using a state (school) physical form.
- Telephone Number: Camper’s home phone number; mobile phone is a parent’s mobile number.
- Unit Leader: Scoutmaster or Cubmaster
- Council: CRC/066
- Unit: Troop, Pack, or Crew number
- Your health insurance company and member ID are critical if the camper or staffer must go to the urgent care center or emergency room. (We no longer need a copy of your health insurance card.)
- Health History: By using the fillable form, you can just click on each item and type in any explanations as needed.
Part B2: General Information/Health History (Page 2)
- Allergies: Does the camper have allergic reactions to food, medications, plants, and/or insects that could require medical treatment? If the answer is yes to any of the allergens, an Emergency Treatment Plan for Allergic Reactions form from the examining Physician/PA/APRN must be attached to the physical form. (This replaces the old allergy treatment plan form.)
- Immunization history with dates or a copy of immunization history from doctor’s office. If using a copy of the immunization history, it must be a legible copy signed and dated by the physician. Your health care provider may write “Up-To-Date” and sign in the box.
- Tetanus must be within 10 years. Please enter this date regardless if using an immunization history.
- Medications: This form is used by the BSA nationally, but Connecticut has special requirements for the administration of medications in camps, schools, etc. In Part D, there is a listing of medications that can be administered at camp without a physician’s order. It is very limited. For all other medications, both prescribed and over the counter, an Authorization for Administration of Medication form must be completed, signed, and dated by the physician and parent. A separate form is required for each medication. NOTE: All medications must be physically checked by the nurse at check-in.
Part C: Physical Examination
- Signed and dated by doctor within 1 year of first day of camp. (In the event that the physical exam falls within the 30 days prior to your week at camp, you may submit the previous year’s physical.)
Part D: Connecticut Rivers Council Addendum
- Completed, signed and dated by parent or guardian. This is required by the State of Connecticut.
Camp Food Accommodation Request
If you have food allergies or religious dietary restrictions, complete this form. It must be received, without exception, at least 2 weeks prior to your arrival at camp. We do not have a Kosher or Halal kitchen nor a vegetarian option however arrangements can be made for you to supply any special foods that your diet may require.
- If a camper is only prescribed emergency allergy medication (i.e. Epi-Pen or Rescue Inhaler), then only the Emergency Treatment Plan for Allergic Reactions form is required. The Authorization for Administration of Medications form is not required.
- All medications will be given at the health lodge before meals. It will be the camper’s responsibility to get there.
- Adults (18+) with medications: You are permitted to administer your own medications; however, you must store them under lock and key or in the Health Lodge. Due to safety regulations, with the exception of Rescue Inhalers and Epi-Pens, no medications may be kept in the campsite(s).
Make copies of all medical forms prior to submission. All medical forms should be submitted to camp at least three weeks prior to your arrival at camp. The medical form linked from this page can be filled out on the computer using Adobe Reader; many items auto-fill after you enter them the first time.
Mail all forms to:
169 Camp Workcoeman Road
New Hartford, CT 06057
Do not fax or email forms to camp.
Please include a roster of those Scouts and Scouters attending camp when sending medical forms. Include phone and email contact information for one primary contact for all medical form questions. If you have a preferred check-in time, please let us know and we will try to accommodate you.
Our health officers will review all forms and inform your troop medical contact or parents with any problems to address prior to your arrival at camp. Please understand that submitting all forms three weeks ahead of your troop’s week at camp will help streamline your check-in process.
Upon arrival, all Scouts and Scouters must fill out a Medical Screening Questionnaire. The survey form can be found at the bottom of this page. These surveys are to be turned in to the Health Officers during your Sunday medical check-in.
During the week prior to your arrival at camp, Troop leadership will be provided a time for your Sunday check-in with the Health Officers. Check-in times begin at 1:00 PM. If your unit has a preferred check in time, please submit it with your medical forms
Failure to follow this procedure will negatively affect the check-in schedule of all troops in camp.
Email all medical related questions to [email protected] or call (860) 379-1756 (after June 27).