SPRING 2018 CAMPOREE MANUAL

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2 SPRING 2018 CAMPOREE MANUAL April 27, 28, 29 - Fort de Chart res Prairie du Rocher, Illinois Senior Patrol Leaders, Assistant Senior Patrol Leaders, Scout Masters, Assistant Scout Masters, Outing Coordinators and Scouters: Our plans for the Spring Camporee have taken a change due to circumstances beyond our control. This should serve as a good teaching moment on alternative or backup planning. While we were unable to execute our initial plans, we believe your unit will find our alternative plans to be a fun and exciting outing. 14 years ago, we held a Camporee at Fort de Chartres in Prairie du Rocher, Illinois. The site is rich with history, and offers ample camping and activity space, and is considered the most significant French fortification in Illinois, built in the 1750 s. The last camporee held at the fort continues to be talked about by many of those who were present. Over the last 14 years, many have asked to revisit this facility, but due to budgetary constraints within the State of Illinois, we were unable to arrange this (until now). We are in the process of arranging Black Powder shooting and we have made arrangements to have a group of Civil war reinactors present for some of the program. We are also trying to arrange for a group of World War II reinactors to also have demonstrations present as well. Camporee Staff Our Host Staff Troop - Troop 782 from St. Johns Lutheran Church in Ellisville, is working on arranging a program that we believe you will not want to miss out. In order to bring you the best and most exciting program possible, we are asking that if possible, each unit attending send at least 2 scouts to join Camporee Staff. What we do will in part be dependant upon the number of staff we have to execute program. Aside from the tremendous leadership experience your youth will gain by staffing a Camporee, this experience is taken into consideration when applying for a paid position on Camp Staff. The exposure of being a leader within our District has been a help to those who have run for OA Lodge positions in the past. Camporee Staff will have their meals cooked for them by the New Horizons QM Staff. Meals include Friday Night, Cracker Barrel Friday Night, Saturday - 3 Meals plus Crackerbarrel and Sunday Breakfast. There is a $25.00 Staff fee to cover the cost of the meals, a special commemorative patch and a commemorative hat. Staff Development dates are on the following Thursday Evenings at 7:00pm at St. John s Lutheran Church, Manchester Road, Ellisville, MO - March 22, March 29, April 5, April 12, April 19, April 26. Youth working Camp staff should attend as many meetings as is possible. If you are signed up to work camp staff, and you will not be able to attend, please let your Campmaster know in advance. Page 1

3 SPRING 2018 CAMPOREE MANUAL April 27, 28, 29 - Fort de Chartres Prairie du Rocher, Illinois - Page 2 Continued - Reservations, Registration & Check in In order for us to adequately plan for the weekend, we ask that you please sign up as soon as possible. I ask that you also please fill out the reservation form as soon as possible and send that into me by . We will not hold you to those numbers, but we ask that you please give us as close to your expected count as possible. If you pay for your group on line early and need to add scouts, you will be able to add numbers up to Check in on Friday Night or Saturday morning. On line payment and registration will close on Thursday Night, April 26 at 11:59pm. Registration on line for this camporee should be available shortly if it is not already open. Cost for this camporee will be $15.00 per person attending and Camping (Youth or Adult) in advance and $20.00 after Thursday April 26. We are allowing those who want to come out for just the day on Saturday to do so. For those who are attending, but not camping the cost will be $5.00 per person (youth or Adult) in advance and $7.00 after April 26th. Council s cancelation policy applies. As such if you think that your numbers are going to change, pay for only those that you are certain will be attending. Please be sure to print a copy of your receipt and bring that with you to insure that your unit receives the proper payment credit. If you feel that you have a unique reason to receive a refund, please contact your Mr. Sobelman Camping Locations We hope to be able to preassign camping locations in by Thursday Evening April 26th. If you do not receive a campsite location in advance, one will be assigned to you on check in. Please do not start unpacking and setting up camp unless you have a camp location. The number of tents that you pitch are an important factor in our cost. Please let us know the approximate number of tents that your unit plans to use. Do not include your fly s in this count. Cooking & Fires All attending units will be using the patrol method for Cooking. Each unit will be responsible for their own food and cooking supplies. There are to be NO GROUND FIRES. Cooking will be either on Gas Stove, Raised Charcoal Grill or on a raised Fire Pit. If your unit does not have a Fire Pit to use our District has several that you may use or borrow. Please make arrangements with Mr. Sobelman in advance to reserve one. These will be available on a first come basis. Cub Scouts in Attendance. We have once again opened this event up to participation from our Cub Scout Units, for the following (current ranks) - Wolf, Bear, Webelos and Arrow of Light Scouts. If a cub scout unit wants to attend and Camp, please see tenting and camping guidelines. Page 2

4 SPRING 2018 CAMPOREE MANUAL April 27, 28, 29 - Fort de Chartres Prairie du Rocher, Illinois - Page 3 Continued - Tenting/Camping The Guide to Safe Scouting (GSS) must be strictly followed - No Exceptions. Cub Scouts that choose to camp are asked to team up with a Boy Scout Unit to assist them with their camping, cooking and equipment needs. This is an excellent opportunity for the Boy Scout units to recruit. Bear and Wolf Scouts should be "Family Camping" with a parent or guardian in the same general area as their host/partner Troop. Webelo and Arrow of Light Scouts may camp in the same general area as their host/partner troop. The boys should not tent with boys outside of their age group and should be accompanied by at least two adults per 6-8 boys to supervise them as long as this is done with parental or guardian consent. Youth may not tent with any Adult that is not their own parent or guardian. Boy Scout Troops and Venture Crews should camp in accordance with GSS Guide lines. Parking In many areas of the park, parking is limited. All vehicles should be parked parallel to the road, but no vehicle should be parked on the gravel or asphalt roads due to safety requirements. There are a couple of parking lots that can be used as satellite parking if roadside parking is not available in your area. If you stop to unload gear, please try to pull off the road as best as possible to unload. Once you are unloaded, please more your vehicle to one of the satellite parking areas. Please try to carpool and use as few vehicles as possible. All vehicles should have a completed Parking Permit sheet face up on the dashboard at all time. Safety & Security Any youth leaving your unit s location should go in groups of 2 or more (Buddy System). Any youth found venturing off on his own will be ex courted back to his campsite by 2 Youth Staff Members. If youth staff members are not available at that time, the youth may have to sit at Camporee HQ until an escort is available. Should you see an adult that is seemingly out of place and not in uniform, please report his presence to Camporee HQ. Evening & Quite Hours On both Friday and Saturday evening, the following will apply: 10:30pm - Return to your Campsite 11:00pm - Curfew and Quite Hours commence. All youth should be in your campsites and adhering to quiet hours. With Scoutmaster s Permission, youth may sit around a campfire - (fire Pit) after 11:00pm as long as they are considerate of those in tents nearby. Youth failing to adhere to quite hours may have this privilege revoked and sent to their tent. Page 3

5 SPRING 2018 CAMPOREE MANUAL April 27, 28, 29 - Fort de Chartres Prairie du Rocher, Illinois - Page 4 Continued - Camp Code The Scout Oath and Law will be the Law will govern conduct. As Scouts, we are expected to be courteous and respectful of our fellow Scouts, Scouters and those in the general public that may be rouing the property. Garbage & Trash Removal & Check-out We expect to have a Dumpster available to us on location. However, if that dumpster is full, we ask you to take your Garbage home with you and dispose of it there. All Campsites must be inspected by Camporee Staff, before you can depart on Sunday Morning. All units are expected to Check Out. If you need to checkout early, please contact Mr. Sobelman to make special arrangements for your Check Out. Please have your evaluation forms filled out and ready to turn in at checkout. You will not be checked out until you have completed SM and SPL evaluation forms completed. Check Out will begin at 08:30 am Sunday Morning. Send a Runner to the New Horizons HQ with your completed evaluation forms. Two Staff members will escort your youth back to camp or we will radio staff teams in the field to meet at your campsite for checkout. Liquid and Pressurized Fuels: Use of Pressurised Fuels should conform to Current Council Policy. Current Pressurized Fuel training is not currently required, but it is strongly recommended. Use of all fire excellerants (Gas, Kerosene, lighter fluid, etc.) is stictl y prohibited to start fires. Kerosene or white gas may be used in approved lanterns or stoves designed for such fuel. Tobacco Usage No person under the age of 18 is allowed to use tobacco Products. Violators will be asked to leave. All Adult smokers are asked to refrain from smoking around or in sight of the youth. Prohibited Items: Sheath Knives, Alcohol, Fireworks, Firearms and non-medically prescribed drugs are STRICTLY PROHIBITED. Violations of any of these Prohibited items may result in the youth or adult being asked to leave. This is a ZERO TOLERANCE guideline. Service Project As has been the case for the last several Camporees, we are trying to arrange for a service project for everyone to participate in. Please see the upcoming addendum which will include details on what equipment is needed. Page 4

6 SPRING 2018 CAMPOREE MANUAL April 27, 28, 29 - Fort du Chartres Prairie du Rocher, Illinois - Page 5 Continued - Saturday Lunch We strongly suggest that Units plan on making Sack Lunches for Satruday s Lunch. These can be prepared Saturday Morning and carried by all throughout the morning. Units may find that they are pressed for time at the lunch hour and it could be difficult for them to get back to their campsite and prepare and eat lunch. Religious Services We are planning on having religious services at 7:00pm on Saturday Evening, pending availability of Clergy. If individual services are not available, we will have a non-denominational service for all in camp. See our upcoming addendum for additional information on this. Packing List Reminders 1. Remind your participants to bring durable rain gear. We will have Weather - this time of year weather is also very unpredictable. 2. Water-Proof footwear & Extra Socks 3. Warm Sleeping bag. THe area we are camping is know to be colder than projected in St. Louis at night. 4. Folding Camp Chair 5. Water bottle, Day Pack and personal First Aid Kit. 6. Sun Screen and a Hat - yes, even in cloudy weather. 7. Yard tool for Service Project. 8. Flash light or Head Light. Emergency Preparations (E.P.) and Emergency Action Plan (E.A.P) We will be sending out a addendum in the upcoming weeks wich will include our EAP Campfire Program and We will have a Campfire Program at 8:00PM on Saturday, Oct. Each unit is asked to bring with it at least one skit and at Page 5

7 New Horizons Spring 2018 Camporee Code of Conduct: Early Arrivals: Roster Cooking Fires and Ground Camp Fires: Generators Pressurized Fuels Use of Accelerants Use of Water Tenting Garbage Tobacco Early Departures Prohibited at ALL Time RULES & REGULATIONS The Scout Oath and Law will be the Law of the Camporee. Camporee Participants - Youth & Adult No Arrivals prior to 5:00 pm. No Exceptions Anyone arriving before 5:00 pm will be asked to wait Camporee Staff - Youth not to arrive before 4:00pm Checkin will be at the N.H. HQ Tent until 8:30 pm. Troop Roster Form is provided with this packet. We will offer an Excel Spread Sheet Roster for your convenience. Note: We are asking you to provide us with a number of tents that you will be using. This is an important part of. rate structure to the State of Illinois. Ground Fires are NOT Permitted. Cooking will be by Gas Stove Charcoal Grill or on an elevated Fire Pit. Camp fires are permitted in elevated fire pits Only. Depending upon wind conditions you may be asked to limit or put out your camp fire. No unattended fires allowed. Generators are NOT permitted for Participant or Unit usage. (exception for District Camporee Staff only) Pressurized Fuels Training is HIGHLY suggested. Use of lanterns or stoves must be in accordance with current council policy and devices should be checked for leaks before use. Use of Kerosene, Lighter Fluid, Starter Fluid or Gasoline to start fires by Scout or Unit Leaders is Strictly PROHIBITED!! Water sources are only for filling water containers. These are not to be used for personal hygene, washing or rinsing dishes or clothes It is our hope to be able to assign camping locations prior to the camporee weekend. If we are unable to do so, assignments will be made at checkin. Each unit must take their trash to one of the dumpsters stationed nearby. If the dumpster is full, you may have to take your trash home with you. No person under the age of 18 is allowed to use tobacco products. All Adult smokers are encouraged to refrain from smoking around Youth. Violators will be asked to leave the property. Depending on conditions Units needing early departure on Sunday should make prior arrangements with the Campmaster Advisor or the District Camping Chairman. ALCOHOL, FIREWORKS, FIRE-ARMS, SHEATH KIVES AND NON-MEDICALLY PERSCRIBED DRUGS ARE STRICTLY PROHIBITED AT ALL TIMES

8 TM BOY SCOUTS OF AMERICA GREATER ST. LOUIS AREA COUNCIL New Horizons 2018 Spring Camporee - Fort de Chartres April , 2018 Reservation Form Please Print Clearly! Please Print Clearly! Unit: Pack Troop Crew # Leader Name: Unit Position Address: City State Zip Cell Phone # Home Phone # address: Number of Youth & Adults Camping Number of Youth & Adults coming for just Saturday $15.00 Per Person $ 5.00 Per Person Anticipated Number of Tent Footprints - Friday Anticipated Number of Tent Footprints - Saturday 1. Please send your reservation form in as soon as possible with as accurate of a count as possible. 2. Additions and cancellations from this count will be permitted. 3. Payment is permitted on line. Please pay for only those you are sure will attend. Once paid, it is Council s policy that there are no refunds. 4. You will be allowed to add people up until check in. However, those added on site at checkin will be at a higher rate of $20.00/per person for those camping and $8.00 for those coming for just the day. 5. Please remember to print a copy of your payment receipt and bring that with you to assure that you receive proper payment credit. 6. If mailing a check, checks should be made payable to GSLAC. or Mail your reservation form ASAP to newhorizonscamping@gmail.com Planning for these events are extremely complicated and it is critical that we know how many to plan for. Your cooperation in providing us with your reservation as early as possible will be greatly appreciated. New Horizons District Questions - Contact: Steve Sobelman Phone: or Mail Reservation form to: Steve Sobelman New Horizons Camping Kimwood Ct. Chester eld, MO newhorizonscamping@gmail.com or smsobelman@gmail.com

9 2018 Spring Camporee Fort de Chartres - Prairie du Rocher, Illinois New Horizons - Unit Roster Unit Type & Number: If If Enter Number of Camping $ Camping Saturday Tent Number Saturday Only $ 5.00 Place 1 Only Footprint Totals: Youth Name Parent'sCell Phone Below Place 1 Enter 1 or Adult Name Cell Phone # Address If If Enter Camping Saturday Tent Place 1 Only Footprint Below Place 1 Enter 1 or

10 New Horizons Camporee Staff Application SPRING April 27, 28, 29 Fort de Chartres - Prairie du Rocher, IL Please PRINT Dates: March 22, March 29, April 5, April 12, April 19, April 26 Time: 7:00pm Place: St. John s Lutheran Church Manchester Road Ellisvile, MO Adult Youth Name Troop # Date Address City & Zip Phone: Cell Phone: Date of Birth Current Age Rank: Star Life Eagle Other-Specify: Dietary Restrictions: Work Related Restrictions: Everyone BSA Part A & B Health Form Turned in BSA Part A & B Health Form Copy Maintained by Host Troop All Staff is Expected to: you must contact the Youth or Adult Campmaster Advisor to arrange for an excused absence. Also be sure to contact your Activity Director to make sure your responsibilities are covered. 2. You MUST remain on Camporee site on Sunday morning of Camporee until Camporee is Closed and have been checked out. In the event that this is not possible, please contact the District Camping Chairman prior to the start of camporee for permission to depart early. activities with your home unit. 4. On the Friday of Camporee Weekend, youth may not arrive at the camporee location before 4:00pm. There is a Staff Fee of $25.00 per person for each Youth or Adult serving on Camporee Staff. This fee covers the cost of your meals for the weekend (Including Friday Dinner and Sunday Breakfast. This fee also covers a limited edition commemoritive hat or T-Shirt as well as a commemoritive Staff Patch. This fee must be paid at one of the Staff Development meetings to a member of the N.H. QM or Camporee Staff. Please pay by CASH if possible. If not, your check should be made payable to: Steve Sobelman. Camporee Staff Fee $25.00 Amt. Paid Date Received By: Parent or Guardian Name (Print) Signature: Date: If you are not a member of the Host Troop, Scoutmaster s signature is Required. available for Troop Duties or participation during this event. Scoutmaster s Name (Print) Signature: Date:

11 Assigned Campsite Location Pack Troop Crew District New Horizons Camporee Parking Permit Unit # FALL WINTER SPRING Driver s First Name Driver s Last Name YEAR 2018 Print Legibly and PLACE ON DASH OF VEHICLE Driver s or Unit Cell Phone Contact while on Property Vehicle Year Vehicle Make Vehicle Model

12 New Horizons Camporee Spring Camporee 2018 Month: Year: SCOUTMASTER S CAMPOREE EVALUATION FORM TROOP # Circle the number that best represents your answer. Put any special comments in the comments section for each answer. Number 1 being liked least, Number 6 liked most. 1. Rate your troop s FUN factor? Comments: 2. Did the Camporee meet your expectations? Comments: Were the activities areas well planned and executed? Comments: What events did you like. How could we make these events better if done again? Comments: 5. Suggestions for future Camporees, Activities or Themes Comments: Thank you for your time. Your opinions are important to us!

13 New Horizons Camporee Spring Camporee 2018 Month: Year: SPL CAMPOREE EVALUATION FORM TROOP # Circle the number that best represents your answer. Put any special comments in the comments section for each answer. Number 1 being liked least, Number 6 liked most. 1. Rate your troop s FUN factor? Comments: 2. Did the Camporee meet your expectations? Comments: Were the activities areas well planned and executed? Comments: What events did you like. How could we make these events better if done again? Comments: 5. Suggestions for future Camporees, Activities or Themes Comments: Thank you for your time. Your opinions are important to us!

14 Part A: Informed Consent, Release Agreement, and Authorization Full name: DOB: High-adventure base participants: Expedition/crew No.: or staff position: Informed Consent, Release Agreement, and Authorization I understand that participation in Scouting activities involves the risk of personal injury, including death, due to the physical, mental, and emotional challenges in the activities offered. Information about those activities may be obtained from the venue, activity coordinators, or your local council. I also understand that participation in these activities is entirely voluntary and requires participants to follow instructions and abide by all applicable rules and the standards of conduct. In case of an emergency involving me or my child, I understand that efforts will be made to contact the individual listed as the emergency contact person by the medical provider and/or adult leader. In the event that this person cannot be reached, permission is hereby given to the medical provider selected by the adult leader in charge to secure proper treatment, including 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 medical staff, camp management, and/or any physician or health-care provider involved in providing medical care to the participant. Protected Health Information/ Confidential Health Information (PHI/CHI) under the Standards for Privacy of Individually Identifiable Health Information, 45 C.F.R , , etc. seq., as amended from time to time, includes examination findings, test results, and treatment provided for purposes of medical evaluation of the participant, 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. (If applicable) I have carefully considered the risk involved and hereby give my informed consent for my child to participate in all activities offered in the program. I further authorize the sharing of the information on this form with any BSA volunteers or professionals who need to know of medical conditions that may require special consideration in conducting Scouting activities. With appreciation of the dangers and risks associated with programs and activities, on my 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 of America, the local council, the activity coordinators, and all employees, volunteers, related parties, or other organizations associated with any program or activity. I also hereby assign and grant to the local council and the Boy Scouts of America, as well as their authorized representatives, the right and permission to use and publish the photographs/film/videotapes/electronic representations and/or sound recordings made of me or my child at all Scouting activities, and I hereby release the Boy Scouts of America, the local council, the activity 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 reproduction, sale, copyright, exhibit, broadcast, electronic storage, and/or distribution of said photographs/film/videotapes/electronic representations and/or sound recordings without limitation at the discretion of the BSA, and I specifically waive any right to any compensation I may have for any of the foregoing.! NOTE: Due to the nature of programs and activities, the Boy Scouts of America and local councils cannot continually monitor compliance of program participants or any limitations imposed upon them by parents or medical 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 programs or activities below.! List participant restrictions, if any: None 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, Philmont Training Center, Northern Tier, Florida 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) Second parent/guardian signature for youth: Date: (If required; for example, California) Complete this section for youth participants only: Adults Authorized to Take to and From Events: You must designate at least one adult. Please include a telephone number. Name: Telephone: Name: Telephone: Adults NOT Authorized to Take Youth To and From Events: Name: Telephone: Name: Telephone: Printing

15 Part B: General Information/Health History Full name: DOB: High-adventure base participants: Expedition/crew No.: or staff position: Age: Gender: Height (inches): Weight (lbs.): Address: City: State: ZIP code: Telephone: Unit leader: Mobile phone: 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: Hypertension (high blood pressure) Adult or congenital heart disease/heart attack/ /chest pain (a angina)/heart murmur/coronary artery disease. Any heart surgery or procedure. Explain all yes answers. Family history of heart disease or any sudden heartre elated death of a family member before age 50. Stroke/TIA Asthma Last attack date: Lung/respiratory disease COPD Ear/eyes/nose/sinus problems Muscular/skeletal condition/muscle or bone issues Head injury/concussion Altitude sickness Psychiatric/psychological or emotional difficulties Behavioral/neurological disorders Blood disorders/sickle cell disease Fainting spells and dizziness Kidney disease Seizures Last seizure date: Abdominal/stomach/digestive problems Thyroid disease Excessive fatigue Obstructive sleep apnea/sleep disorders List all surgeries and hospitalizations CPAP: Yes No Last surgery date: List any other medical conditions not covered above Printing

16 Part B: General Information/Health History Full name: DOB: Allergies/Medications Are you allergic to or do you have any adverse reaction to any of the following? High-adventure base participants: Expedition/crew No.: or staff position: Yes No Allergies or Reactions Explain Medication Food Yes No Allergies or Reactions Explain Plants 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 INDICATE ON A SEPARATE SHEET AND ATTACH. Medication Dose Frequency Reason YES NO Non-prescription medication administration is authorized with these excepti eptions: Administration of the above medications is approved for youth by: / Parent/guardian signature MD/DO, NP, or PA signature (if your state requires signature)!! Br ring enough medications in sufficient quantities and in the original containers. Make sure that they are NOT expir ed, including inhalers and EpiPens. You SHOULD NOT STOP taking any maintenance medication unless instructed to do so by your doctor. Immunization The following imm munizations are recommended by the BSA. 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. Yes No Had Disease Immunization Date(s) Please list any additional information about your medical history: Tetanus Pertussis Diphtheria Measles/mumps/rubella Polio Chicken Pox Hepatitis A Hepatitis B Meningitis Influenza Other (i.e., HIB) Exemption to immunizations (form required) DO NOT WRITE IN THIS BOX Review for camp or special activity. Reviewed by: Date: Further approval required: Yes No Reason: Approved by: Date: Printing

17 Individual s Health Insurance Card Name Please remeber to copy both sides of your current health insurance card and attach those copies to this page.

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20 Near Miss Incident Information Report (A near miss does not result in injury, illness, or damage by definition, but it had the potential to do so.) Near miss incident date: Time: Reporting date: Time: Council/BSA location: Reporting person: Leader Parent Other: Contact information: Location of near miss: Specific area where near miss occurred: Cause of near miss: Activity at time of near miss: Program/event/adventure code: Description of the near miss (detailed): Did the near miss occur while transporting to/from an activity? Yes No Potential severity: Catastrophic I Critical II Marginal III Negligible IV Unknown (See the back of this sheet for definitions.) Lessons learned (what could be done to prevent future occurrences): Witnesses (See the back of this sheet to enter.) Return this completed form to your council s designated user for entry into RiskConsole via MyBSA Incident Entry.

21 Near Miss Incident Information Report (A near miss does not result in injury, illness, or damage by definition, but it had the potential to do so.) Probability/Severity Definitions Catastrophic I Examples: Fatal or lifetime impairment, loss of sight or limb or permanent facility loss or events with multiple critical incidents or > $1 million in financial impact. Critical II Examples: Temporary impairment requiring rehabilitation and/or lifetime partial impairment, loss of use of but not loss of a limb or facility not a total loss but must be rebuilt or events with multiple marginal incidents or < $1 million and > $100,000 in financial impact. Marginal III Examples: Injury requires a physician to treat a temporary impairment with complete rehabilitation possible or sutures, clean fractures, injuries requiring transport to off-site medical facilities or events with multiple negligible incidents or < $100,000 and > $1,000 in financial impact. Negligible IV Examples: First-aid injuries not requiring medical professional intervention or < $1,000 in financial impact. Witnesses Name: First Middle Last Address: City State Zip Home phone: Cell phone: Work phone: Adult leader s name: Others Address: First Middle Last City State Zip Home phone: Cell phone: Work phone: Information gathered at scene by: Contact information: Return this completed form to your council s designated user for entry into RiskConsole via MyBSA Incident Entry Printing

22 Directions to Ft. de Chartres - Prairie Du Rocher, IL 1) Take I 270/I255 Soiuth across Mississippi River 2) at IL Route 3 Exit to right and go south on IL Rt. 3 3) Take IL. Rt. 3 to Red Bud, IL. Continue South on IL Rt. 3 to Ruma, IL.

23 Directions to Ft. de Chartres - Prairie Du Rocher, IL Page 2 4) At Ruma IL, take IL Rt. 155 to the right and go west to Prairie Du Rocher 5) At Prairie Du Rocher IL, Continue on IL Rt Fort du Chartres is approx. 3-4 miles past Prairie Du Rocher on your Left.

24 Directions to Ft. de Chartres - Prairie Du Rocher, IL Page 3