Girl Scouts Heart Of Central California, Girl Emergency Health Information Form

Download a blank fillable Girl Scouts Heart Of Central California, Girl Emergency Health Information Form in PDF format just by clicking the "DOWNLOAD PDF" button.

Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.

Complete Girl Scouts Heart Of Central California, Girl Emergency Health Information Form with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.

Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.

ADVERTISEMENT

Girl Emergency Health Information
Girl Scouts Heart of Central California I 6601 Elvas Avenue Sacramento, CA 95819 I
This form is to be completed and signed by parents/guardians of the girl and updated annually.
Name _________________________________________________________________ Birthdate____________ Troop # _________________________
Address _________________________City _______________________Zip _________ Home phone (_____) ___________________________________
Family medical/hospital insurance carrier ____________________________________ Policy or Group No. ____________________________________
Parent/Guardian __________________________________________ Parent/Guardian ___________________________________________________
Day Phone (_____) _________________________________________ Day Phone (_____) __________________________________________________
Evening Phone (_____)______________________________________ Evening Phone (_____)_______________________________________________
Emergency Contacts (in the event parents cannot be reached)
Name____________________________________________________ Name_____________________________________________________________
Relationship ______________________________________________ Relationship _______________________________________________________
Day Phone (_____) _________________________________________ Day Phone (_____) __________________________________________________
Evening Phone (_____)______________________________________ Evening Phone (_____)_______________________________________________
Cell Phone (_____) _________________________________________ Cell Phone (_____) __________________________________________________
Email ____________________________________________________ Email _____________________________________________________________
The child may NOT be released to the following individuals:
Name____________________________________________________ Name_____________________________________________________________
Relationship ______________________________________________ Relationship _______________________________________________________
Phone (_____)_____________________________________________ Phone (_____)______________________________________________________
Does the participant have any allergies, special needs or a special diet we should be aware of? □ Yes □ No
If Yes, please explain:___________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________________
(For example, please list all medications, plants, animals, etc. that the participant is allergic to and/or indicate whether the participant has special
needs like asthma or diabetes.)
Please provide any information in relation to the care of the participant that would be useful to the adult in charge. Also indicate any activities to be
encouraged or restricted. _______________________________________________________________________________________________________
_____________________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________________
The above information is correct to the best of my knowledge, and my daughter has my permission to engage in all activities, except as noted. I
hereby authorize Girl Scouts Heart of Central California, through the adult person(s) caring for my daughter, to order emergency X-rays, anesthetic,
medical or surgical diagnosis or treatment and hospital care as deemed advisable by a licensed physician. It is understood that every reasonable
effort will be made to contact me or the person noted above before taking this action. I understand that this permission is given in advance of need
for any diagnosis, treatment, or hospitalization. This authorization shall remain effective throughout the entirety of the individual’s membership in the
Girl Scouts Heart of Central California.
I agree to inform a troop or activity leader of any changes in the above information. For example, if a Girl Scout later develops an allergy or contagious
disease or is no longer allowed to participate in a particular activity, the parent or individual must inform the troop or activity leader to ensure the
safety of both the individual and those around her.
_______________________________________________________
_____________________________________________________________
Date
Signature of parent/guardian
_______________________________________________________
_____________________________________________________________
Updated
Signature of parent/guardian
_______________________________________________________
_____________________________________________________________
Updated
Signature of parent/guardian
All Girl Scouts registered in the USA are insured by:
#655g – rev – 7/10 – LW:js
MUTUAL OF OMAHA INSURANCE COMPANY
Girl Scout Division, Group Policy #SGS-2-8012 6-3632
Dodge at 33
Street Omaha, Nebraska 68175
rd

ADVERTISEMENT

00 votes

Related Articles

Related forms

Related Categories

Parent category: Business
Go