Girl Scouts Of Northern California Camper Health Record And Emergency Information Form printable pdf download

GIRL SCOUTS OF NORTHERN CALIFORNIA

CAMPER HEALTH RECORD AND EMERGENCY INFORMATION

This part to be filled in by adult and reviewed with practioner at the time of examination

Name (Last, First, Initial)

Birth Date

Grade

Address

City/Town

State

Zip

Phone

(

)

Parent/Guardian’s

(1) Name

E-Mail Address (For GSNC use only)

Home Phone

(

)

Place of work

Title

Work Phone

(

)

Parent/Guardian’s

(2) Name

E-Mail Address (For GSNC use only)

Home Phone

(

)

Place of work

Title

Work Phone

(

)

Name of Alternate Emergency Contact If Parent/Guardian are Unavailable

Relationship

Home Phone

(

)

Address

City/Town

State

Zip

Work Phone

(

)

INSURANCE INFORMATION, PLEASE COMPLETE THE FOLLOWING:

Carrier

ID Number

Group Number

Member Services Phone Number

Address

City/Town

State

Zip

(

)

HEALTH HISTORY: (Check those that apply)

SUGGESTION FROM

DISEASES:

ALLERGIES:

CHRONIC or

APPLIANCES:

PARENT/GUARDIAN:

 Chicken Pox

 Animals:____________

RECURRING ILLNESS:

 Hearing Aid

My daughter has

 Measles

 Food: ______________

 Ear Infections

 Orthopedic Braces

permission to take or

 German Measles

 Hay Fever

 Heart Defect/Disease

 Glasses

use the following:

 Mumps

 Insect Stings

 Seizures

 Contact Lenses

 Tylenol/Acetaminophen

 Rheumatic Fever

 Medicine/Drugs:______

 Bleeding Disorders

 Dental Braces

 Advil/Ibuprofen

 Tuberculosis

 Plants:______________

 Asthma

 Retainer

 Sudafed/decongestant

 Kidneys

 Pollen

 Hypertension

 Other

:__________

 Benadryl/antihistamine

(specify)

 Other

 Diabetes

____________________

 Pepto Bismol

(specify)

 Musculoskeletal

 Tums/antacid

____________________

Disorders

 Robitussin/expectorant

____________________

 Arthritis

 Swimmer’s Ear/alcohol-

____________________

 Sinusitis

vinegar solution

____________________

 Other

 Cough drops

(specify):

DETAILS OF ANY CHECKED ITEMS ABOVE (i.e. allergic reactions to bee stings, food, or medications/drugs)

PLEASE DESCRIBE CONDITIONS AND GIVE DATES:

Operations or serious injuries:

Hospitalizations:

List any other diseases or disabilities:

Fainting

Sleep Disturbances

Bed Wetting

Menstrual Cramps

Constipation

Nosebleeds

Emotional Disturbances

Other (Specific)

Specific Activities to be Encouraged

Restricted

Any known recent exposure to contagious disease(s) within the last 6 weeks?  YES

 NO

If YES, give details:

Have you talked to your girl about menstruation?  YES

 NO

Has she started menstruating?  YES

 NO

Is your child currently under care of physician or psychologist?  YES

 NO

If YES, give details:

Special medical or dietary regimen to be followed (specify):

PARENT CONSENT: This Camper Health Record and Emergency Information is complete and accurate to my

knowledge. My daughter has permission to engage in all prescribed activities, except as noted by me and by

the examining physician. I give permission for her to receive emergency medical and surgical treatment and to

be hospitalized, if necessary. It is understood that every effort will be made to contact me or the person(s)

noted above before taking this action.

SIGNATURE OF PARENT/GUARDIAN:

DATE:

Girl Scouts Of Northern California Camper Health Record And Emergency Information Form

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