Girl Scouts Of Northern California Camper Health Record And Emergency Information Form (Page 2 of 2) in pdf

Girl Scouts of Northern California

CAMPER HEALTH RECORD AND EMERGENCY INFORMATION (page 2 of 2)

Name:

Date:

This part to be filled in by licensed practitioner after review of health history with parent/guardian

HEALTH EXAMINATION

RECORD OF IMMUNIZATION

Immunization

Year Primary

Year of

Height

Weight

B.P.

Series Completed

Last Booster

DTaP

Appearance-Nutrition

Diphtheria

Pertussis

(Whooping Cough)

Without Glasses:

With Glasses:

Tetanus

(within last 10 years)

Eyes R 20/

L 20/

R 20/

L 20/

Oral Polio/IPV

Ears

Hearing R

Measles

Mumps

CODE:

Satisfactory=S

Not Satisfactory=NS Not Examined=NE

Rubella

Hib

Nose

Throat

Hep B

Teeth

Heart

Lungs

Abdomen

Tuberculin Test Year last given

Result

Genitalia

Hernia

Typhoid and

Paratyphoid

Skin

Musculoskeletal

Cholera

General physical and emotional status

Yellow Fever

Urinalysis*

HGB*

Other notes

Typhus

Rocky Mountain

Spotted Fever

Physician’s comments and recommendations.

Other: (specify)

Give details or indicate management or significant

illnesses.

This person is in satisfactory condition and may engage in

all usual activities except as noted.

Licensed Practioner's Signature

(Print) Licensed Practioner's Name

Address/City/State/Zip

E-Mail

*Not required for every health exam. A girl 11-18 should have

Area Code + Phone

FAX: Area Code + Phone

Date

this test if she has not had it since entering puberty.

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)

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This information is needed to measure how well your council is serving the Bay Area’s diverse population, it will be combined with

everyone in the troop without identifying anyone individually.

Asian

The girl’s racial background is:

American Indian or Alaskan Native

(please check as many as apply)

Black or African American

Hawaiian or Pacific Islander

White

Other(

_________________

specify)

The girl’s ethnic background is:

Hispanic or Latino

Not Hispanic or Latino

(please check one)

Is your girl/ward disabled?

YES If YES, does she need accommodation?

YES If YES, attach a separate paper to explain.

MEDICATIONS: The camp cannot administer medication that is not in its original bottle, labeled with the child’s own name,

accompanied by specific written dispensing instructions by parent/guardian or physician. Medications include, but are not limited to:

prescription, over the counter, vitamins, herbal and homeopathic remedies.

IMPORTANT: PLEASE LIST CURRENT MEDICATIONS BEING TAKEN ON SEPARATE PAPER AND ATTACH—INCLUDE

DOSAGE AND ANY POTENTIAL HARMFUL INTERACTIONS (e.g. food, medications, environmental)

HEALTH INFORMATION PRIVACY STATEMENT

The Camper Health Record and Emergency Information is for health care concerns at the specified event only. 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 of the specific event. Minimal necessary information may be shared with event staff/volunteers in order to provide

adequate participant safety and health care. The Camper Health Record and Emergency Information will be retained by the sponsoring council or

GSUSA until it is destroyed. All forms/records with noted treatment will be retained for seven years past the age of maturity of the participant. Access

to the information will be limited, but copies may be requested from the event sponsor, by the participant or their legal representative.

I have read the above procedures for handling the health form information and I agree to the release of any records necessary for treatment, referral,

billing or insurance purposes.

SIGNATURE OF PARENT/GUARDIAN:

DATE: