Girl Member Information Sheet - Girl Scouts Of Eastern Oklahoma (Page 2 of 2) in pdf

HEALTH INFORMATION PRIVACY STATEMENT

The Girl Health History is for health care concerns. All records will be handled by staff/volunteers whose job includes processing or

using this information for the benefit of the participant. All medical records will be held in limited access by the health care

supervisor. Minimal necessary information may be shared with staff/volunteers in order to provide adequate participant safety and

health care. The Health History will be retained for the current membership year only and will then be destroyed. Access to the

information will be limited, but the participant or their legal representative may request copies from the staff/volunteers. I have read

the above procedures for handling the health history information and I agree to the release of any records necessary for treatment,

referral, billing or insurance purposes.

AUTHORIZATION FOR EMERGENCY MEDICAL CARE

I understand that my daughter should not attend meetings or special activities when she is ill or recently exposed to

a contagious disease. If she should become ill or injured while in the care or under the supervision of Girl Scouts of Eastern

Oklahoma, any of its officers or volunteers, I authorize her to receive first aid and other emergency care. If it should become

necessary for her to receive professional medical, surgical, or dental treatment, I authorize the responsible Council officer or

leader to give the necessary “parental consent” in my stead for a licensed physician, surgeon or dentist to administer any

medical, surgical or dental treatment they deem necessary, including hospitalization and surgery. I understand that every

reasonable effort will be made to contact me immediately upon the discovery of the emergency. I further understand that I

will take full financial responsibility for all expenses that might be incurred that are not covered by Girl Scout insurance.

This consent is given in advance of any specific diagnosis or treatment being required, and is given primarily to encourage

those officers or leaders who have temporary custody of my daughter, and the said physician, surgeon or dentist to exercise

their best judgment in situations deemed an emergency as to the requirements of such diagnosis or medical, surgical or dental

treatment.

I understand this emergency medical care authorization includes my daughter’s participation with her troop during regular

meetings and during Girl Scout activities and special events at a different time or place from regular troop meetings.

By signing this form, I agree that I have thoroughly read the Health Information Privacy Statement and

the Authorization for Emergency Medical Care. I know of no reason(s) other than the information given

on this form why my daughter should not participate in Girl Scouts.

Signature of BOTH parents is required unless one parent has legal custody. Signatures must be in ink.

MOTHER’S/GUARDIAN’S SIGNATURE __________________________________ DATE _________

FATHER’S/GUARDIAN’S SIGNATURE ___________________________________DATE __________

PUBLICITY RELEASE FOR MINORS

I, being Parent or Guardian of ________________________________(“My Child”), hereby consent that the photographs, videotapes,

motion picture film, and/or electronic images for which she posed and/or audio recordings made of her voice may be used by Girl

Scouts of Eastern Oklahoma, an Oklahoma corporation (“Council”), its employees, agents, and representatives, and others authorized

by the Council (“Indemnitees”) in whatever way they may desire, including television. I consent that any such photographs, films,

recordings, electronic images and the negatives/plates, film, or other media upon or from which they were made or produced shall be

their property, and they shall have the right to duplicate, reproduce and make other such use of said photographs, videotapes, motion

picture film, and/or electronic images and/or audio recordings as they may desire, without any claim on the part of My Child or on my

part. I will defend, indemnify, and hold the Indemnitees and each of them harmless from all liability, damage, loss, and claims arising

from or in any way associated with the use by the Indemnitees, or any of them, of the photographs, videotapes, motion picture film,

and/or electronic images and/or audio recordings of My Child as described above.

 PARENT’S/GUARDIAN’S SIGNATURE ______________________________________________ DATE _______________

Please complete other side

Girl Member Information Sheet - Girl Scouts Of Eastern Oklahoma Page 2