Girl Health History Record - Girl Scouts - 2017
ADVERTISEMENT
1Girl
GIRL HEALTH HISTORY RECORD
This health history is to be completed and signed by the Parents/Guardians.
Name
Date of Birth
Age
Address
City
State
Zip
Troop No.
Parent/Guardian
Home Phone (
)
Cell Phone
(
)
In Emergency Notify
Relationship
Name:
Phone:
Name of Family Physician:
Phone (
)
Family Medical/Hospital
Policy or Group No.
Insurance
I _____________________________________ do authorize_______________________________ a representative from the Girl Scout Council of
Greater New York, Inc. (Troop Leader, Co-leader, Council Staff, Camp Staff and/or volunteer) to use the medical information below regarding my
daughter____________________________________, during troop meetings, trips, camping activities, and other Girl Scout events.
Please check appropriate boxes
No medical condition exists that would limit participation in any specific activity.
¨
¨
No known allergies exist.
¨
My daughter is up-to-date with all immunizations and tetanus shots.
¨
The following medical condition / allergies exist_______________________________________________________________
Please indicate how this condition may limit participation________________________________________________________
_____________________________________________________________________________________________________
This authorization shall expire on September 30, 2017.
Signature of Parent/Guardian
Date
_____________________________________________________
_________________________
PERMISSIONS
Please read and initial statements at the space provided
TRANSPORTATION
The responsibility of the Troop Leaders ends at the close of the Troop Meeting. Parent or Guardian is responsible for the
girl’s transportation home. For the Leaders’ information, initial one of the following:
_____________ My daughter may walk home from the Troop Meetings.
_____________ My daughter may not walk home from the Troop Meetings. I will arrange for her transportation home.
EMERGENCY CANCELLATION
There is the possibility that the Volunteer Leaders may have to unexpectedly cancel a Troop Meeting.
________I will tell my daughter what to do if such an emergency should arise.
UNSCHEDULED ACTIVITIES
Occasionally, the Troop will decide to leave their meeting room for a specific activity. The destination of the Troop will be
posted at the regular meeting room, and dismissal of the Troop will be from the regular meeting place at the regular time. No
vehicles will be used for this type of spontaneous activity.
______
I will give permission for my child to participate in unscheduled local activities with her troop during regular Troop
Meeting time.
PHOTOGRAPHS
Occasionally, pictures of the girls during Girl Scouts activities are put in local newspapers and displays
______
I give permission to the Girl Scout Council of Greater New York, Inc. to use photos taken of my child during Girl
Scout activities for Girl Scout publicity.
Signature of Parent/Guardian
Date
_______________________________________________
_________________
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Business