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) to ensure the most up-to-date version.
All participants need parts A, B, C, and D of the BSA Annual Health & Medical Record form completed
and submitted along with any applicable Medication Administration and Food Allergy Treatment Plan forms.
The only exception is that Scouts who cumulatively attend two days or fewer over the course of the summer
do not need Part C (physical). Remember to make copies of all forms before submitting. Only one copy is
needed for the summer. Please mail forms to camp (A n: Health Officer, Camp Workcoeman, 169 Camp
Workcoeman Rd., New Hartford, CT 06057) two weeks in advance or bring to check‐in.
As part of our COVID‐19 mitigation policies, all participants must complete the COVID‐19 Pre‐Event
Medical Screening Checklist and bring it with them to check‐in. A new form is needed for the first day of
each program (but not subsequent days of multi‐day programs).
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.
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.
All four parts of the BSA form must be completed and submitted along with any applicable Authorization for Administration of Medication and/or Emergency Treatment Plan for Allergic Reactions.
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.
- 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. Ideally, all medical forms should be submitted to camp at least two weeks prior to your arrival at camp; if you register less than two weeks in advance, please bring forms to check-in. Only one copy is needed for the entire summer. 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:
Attn: Health Officer
169 Camp Workcoeman Road
New Hartford, CT 06057
Do not fax or email forms to camp.