Parent Guardian Consent And Health History Form printable pdf download

Parent/Guardian Consent

and Health History Form

To the Parent/Guardian: This form, signed by a parent or guardian, is needed prior to a girl

participating in any Girl Scout activity. Parents may wish to make a copy in

case daughter participates in Girl Scout program events without her troop.

To the Leader: Retain this form. This information should be with you at all troop functions (including

troop meetings, trips and camping events).

Girl’s Name_________________________________________ Date of Birth ______________________ Age ________

Home phone(____)______________________________ Cell phone(____)___________________________________

Parent/ Guardian Name_______________________________________ Work phone(____)_____________________

My daughter is under the custodial care of:

Both Parents

Mother Only

Father Only

Other,specify__________________________________

Name of Family Physician_____________________________________ Phone Number________________________

Family Medical/Hospital Insurance Carrier_______________________ Policy or Group #_____________________

Emergency Contact Name (other than parent)____________________________________________________

Relationship to girl______________________________________Home(____)_____________________________

Work(_____)_______________________________________Cell(______)_________________________________

Medical Release: In the event _______________________________becomes ill or sustains an injury while in the care of

or under the supervision of the Girl Scout of Greater Mississippi Council or any of its officers or leaders and it

becomes necessary to seek professional medical treatment, I give my permission to the certified first aider to

provide First Aid and/or CPR and to take the appropriate measures including contacting the emergency medical

services (EMS) system and arranging for transportation to _____________________________or the nearest emergency

medical facility to receive treatment by a licensed physician. I understand that every effort will be made to contact

me or the person designated by me as my emergency contact.

Parent/Guardian Signature_________________________________________________Date_______________________

Photo/Press Release: I, as Parent/Guardian of ________________________, agree that any photographs, and/ or

motion picture or videotape for which she posed, and /or audio recordings made of her voice or words written by her

may be used by the Girl Scout of Greater Mississippi Council, its assignees or successors, in whatever way desired,

including television, CD-ROMS, online and print publications, and any other form for the storage, retrieval and

reproduction of information, images; furthermore, I hereby consent that such information photographs, videos, and

the plates and/or tapes from which they are made shall be their property, and they have the right to sell, duplicate,

reproduce and make other uses of such information, photographs, videos, recordings, plates and tapes as they may

desire free and clear of any claim whatsoever on my part.

Parent/Guardian Signature___________________________________________Date___________________

Rev. July 2011

Parent Guardian Consent And Health History Form