Girl Member Information Sheet - Girl Scouts Of Eastern Oklahoma


Girl Scouts of Eastern Oklahoma
Girl Member Information Sheet
*Please complete both sides of this form and return it to your daughter’s troop leader along with the Girl Member
Registration Form and $15.00 (unless you have submitted the current registration through online registration).
This vital information is kept with the troop leader during all troop activities.
Girl’s Name ___________________________ School __________________ Grade ______ Birthday__________
Address ____________________________ City _____________ Zip ________ Home Phone_______________
Mother/Guardian Name _________________________________Email_______________________________
Place of Employment _____________________________________ Occupation ___________________________
Home Address and Phone
(if different from above)
Daytime Phone _________________ Evening Phone __________________ Cell Phone _____________________
Father/Guardian Name___________________________________Email______________________________
Place of Employment _____________________________________ Occupation __________________________
Home Address and Phone
(if different from above)
Daytime Phone _________________ Evening Phone __________________ Cell Phone ____________________
We are willing to have our daughter participate in troop activities that may include a trip in a car during the troop meeting. We understand that special permission will be
requested for her to attend activities longer than a troop meeting or at a different time or place from a regular troop meeting. We also understand that the Authorization for
Emergency Care includes our daughter’s participation in all troop activities as well as in regular troop meetings. We acknowledge that the registrant will make the Girl
Scout Promise and accept the Girl Scout Law. The registrant has permission to join Girl Scouts and/or participate in this activity.
Emergency Contact
(This person must be someone who knows how to reach you. Please notify this person of their responsibility.)
Name ________________________________________ Relationship ______________________________
(Grandparent, Guardian, Parent, Aunt/Uncle, etc.)
Daytime Phone __________________ Evening Phone _________________ Cell Phone __________________
Transportation to and from meetings
(This information is needed by the troop leader for the safety of your daughter. It will
remain in effect unless the leader is notified in writing.)
Our daughter will go ____________________ after regular troop meetings by ______________ with __________________
(home, day care, other place)
(car, walking, etc.)
(Name of person)
Health History
Name of Family Physician __________________________________________ Phone __________________
Date of last Tetanus Shot _____________________ Date of last Health Examination____________________
Illness and injuries
Other conditions
(check all that apply):
(check all that apply):
 Ear infection
 Bleeding/clotting disorders
 Bed-wetting
 Emotional disturbances
 Hypertension
 Musculoskeletal disorders
 Constipation
 Fainting
 Seizures
 Heart defect/disease
 Menstrual cramps
 Hearing impairment
 Asthma
 Diabetes
 Motion sickness
 Sickle cell trait/disease
 Other ________________________
 Nosebleeds
 Sleep disturbances
 Wears glasses/contact lenses
 Other _____________________________________________
(Check all that apply; specify nature of reaction):
 Animals ____________________________________
 Pollen ______________________________________
Special dietary regimen:
(such as lactose intolerance,
 Hay fever ___________________________________
vegetarianism, and religious considerations): _________________
 Food _______________________________________
 Plants ______________________________________
 Insect bites/stings _____________________________
Activities to be encouraged or restricted
: ____________
 Medicine/drugs _______________________________
 Other (Specify): _______________________________
By signing this form I agree the above information is true and accurate to best of my knowledge.
Signature must be in ink.
PARENT’S/GUARDIAN’S SIGNATURE _________________________________________ DATE ____________
#260F 07/13
Please complete other side


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